Plastic Surgery

SAN DIEGO  – The future of treating hypertrophic and keloidal scars will involve earlier intervention with new and existing technologies – even at the genesis of scar formation, said Dr. E. Victor Ross.

"I think you’re going to see a lot more in the future about scars, not just in the laser area, but also in the biologic arena, because we’re learning more about the way scars behave," Dr. Ross said at a meeting on superficial anatomy and cutaneous surgery. "Some physicians are treating scars as early as the time of Mohs surgery, for example, by applying the PDL [pulsed-dye laser] at the time of suture placement. That’s perhaps a bit extreme, but I think you are going to see newer technologies and drugs used synergistically to give us a better fighting chance to prevent and treat scars."

Photos courtesy Dr. E. Victor Ross

Dr. Ross of Scripps Clinic Laser and Cosmetic Dermatology Center in Carmel Valley, Calif., said that there is a lack of consensus regarding how the two main types of scars hypertrophic and keloidal – are defined. Historically, "we’ve said that hypertrophic scars don’t go beyond the boundary of where the scar tissue was, and keloidal scars go around the perimeter of where the scar boundaries were," he noted. "If the scar is red, even if it’s longstanding, I tend to call it a hypertrophic scar. If it tends to be more flesh colored, and aged like a fine wine, I tend to call it a keloidal scar. The critical thing with these scars is how long it takes the wound to heal. If an open wound takes more than 3-4 weeks to heal, often it will be hypertrophic."

Existing therapies that are commonly used to treat scars include intralesional steroids, intralesional 5-fluorouracil, oral antihistamines, cyclooxygenase-2 inhibitors, lasers, hydrogel sheeting, and compression. "The critical thing is to treat relatively early; you have to use all the weapons that are available to you," Dr. Ross said at the meeting, which was sponsored by the University of California San Diego School of Medicine and the Scripps Clinic.

He said that when treating scars, a modifiable approach should be taken. "You want to modify the scar. After it’s formed, you want to rehabilitate the scar and make it more like the skin around it."

When using intralesional steroids, Dr. Ross prefers to use very low volumes with a very high concentration of Kenalog, "typically 40 mg/mL in tiny amounts with a 3-gauge, half-inch needle," he said. "You want to keep the needle tip relatively superficial. If the steroid floats into the scar too easily you’re probably too deep or under the scar."

He favors using fractional lasers for scars whenever possible. These devices "create microscopic wounds in the skin," he said. "It turns out that if you fractionate a wound, the reservoirs of normal, undamaged skin act as ‘seeds’ to make the wounds heal quickly. I like to use purpuric settings with the pulsed-dye laser. They tend to give you better results than other settings."

For scars that form after thyroid surgery, Dr. Ross likes to use a PDL or IPL (intense pulsed light) to reduce the redness, followed by a nonablative fractional laser. With that tandem approach "you can almost make the scar go away, which is a complete rehabilitation of the scar," he said.

Innovative scar therapies include topical mitomycin C, which has worked well for postoperative keloids; oral and topical tamoxifen, which helps in the formation of fibroblasts; and oral methotrexate, which has demonstrated efficacy in the treatment and prevention of keloids. Imiquimod has also been used, "but I’m not a believer in it," Dr. Ross said. "We’ve tried it several times and we found that it irritated the skin most of the time. Retinoids are good and bad. They decrease fibroblast activity but also decrease collagenase."

Dr. Ross disclosed that he is a consultant for Cutera, Palomar Medical Technologies, and Lumenis. He has also received research support from Palomar, Sciton, and Syneron Medical.

SAN DIEGO  – The future of treating hypertrophic and keloidal scars will involve earlier intervention with new and existing technologies – even at the genesis of scar formation, said Dr. E. Victor Ross.

"I think you’re going to see a lot more in the future about scars, not just in the laser area, but also in the biologic arena, because we’re learning more about the way scars behave," Dr. Ross said at a meeting on superficial anatomy and cutaneous surgery. "Some physicians are treating scars as early as the time of Mohs surgery, for example, by applying the PDL [pulsed-dye laser] at the time of suture placement. That’s perhaps a bit extreme, but I think you are going to see newer technologies and drugs used synergistically to give us a better fighting chance to prevent and treat scars."

Photos courtesy Dr. E. Victor Ross

Dr. Ross of Scripps Clinic Laser and Cosmetic Dermatology Center in Carmel Valley, Calif., said that there is a lack of consensus regarding how the two main types of scars hypertrophic and keloidal – are defined. Historically, "we’ve said that hypertrophic scars don’t go beyond the boundary of where the scar tissue was, and keloidal scars go around the perimeter of where the scar boundaries were," he noted. "If the scar is red, even if it’s longstanding, I tend to call it a hypertrophic scar. If it tends to be more flesh colored, and aged like a fine wine, I tend to call it a keloidal scar. The critical thing with these scars is how long it takes the wound to heal. If an open wound takes more than 3-4 weeks to heal, often it will be hypertrophic."

Existing therapies that are commonly used to treat scars include intralesional steroids, intralesional 5-fluorouracil, oral antihistamines, cyclooxygenase-2 inhibitors, lasers, hydrogel sheeting, and compression. "The critical thing is to treat relatively early; you have to use all the weapons that are available to you," Dr. Ross said at the meeting, which was sponsored by the University of California San Diego School of Medicine and the Scripps Clinic.

He said that when treating scars, a modifiable approach should be taken. "You want to modify the scar. After it’s formed, you want to rehabilitate the scar and make it more like the skin around it."

When using intralesional steroids, Dr. Ross prefers to use very low volumes with a very high concentration of Kenalog, "typically 40 mg/mL in tiny amounts with a 3-gauge, half-inch needle," he said. "You want to keep the needle tip relatively superficial. If the steroid floats into the scar too easily you’re probably too deep or under the scar."

He favors using fractional lasers for scars whenever possible. These devices "create microscopic wounds in the skin," he said. "It turns out that if you fractionate a wound, the reservoirs of normal, undamaged skin act as ‘seeds’ to make the wounds heal quickly. I like to use purpuric settings with the pulsed-dye laser. They tend to give you better results than other settings."

For scars that form after thyroid surgery, Dr. Ross likes to use a PDL or IPL (intense pulsed light) to reduce the redness, followed by a nonablative fractional laser. With that tandem approach "you can almost make the scar go away, which is a complete rehabilitation of the scar," he said.

Innovative scar therapies include topical mitomycin C, which has worked well for postoperative keloids; oral and topical tamoxifen, which helps in the formation of fibroblasts; and oral methotrexate, which has demonstrated efficacy in the treatment and prevention of keloids. Imiquimod has also been used, "but I’m not a believer in it," Dr. Ross said. "We’ve tried it several times and we found that it irritated the skin most of the time. Retinoids are good and bad. They decrease fibroblast activity but also decrease collagenase."

Dr. Ross disclosed that he is a consultant for Cutera, Palomar Medical Technologies, and Lumenis. He has also received research support from Palomar, Sciton, and Syneron Medical.

SAN DIEGO  – The future of treating hypertrophic and keloidal scars will involve earlier intervention with new and existing technologies – even at the genesis of scar formation, said Dr. E. Victor Ross.

"I think you’re going to see a lot more in the future about scars, not just in the laser area, but also in the biologic arena, because we’re learning more about the way scars behave," Dr. Ross said at a meeting on superficial anatomy and cutaneous surgery. "Some physicians are treating scars as early as the time of Mohs surgery, for example, by applying the PDL [pulsed-dye laser] at the time of suture placement. That’s perhaps a bit extreme, but I think you are going to see newer technologies and drugs used synergistically to give us a better fighting chance to prevent and treat scars."

Photos courtesy Dr. E. Victor Ross

Dr. Ross of Scripps Clinic Laser and Cosmetic Dermatology Center in Carmel Valley, Calif., said that there is a lack of consensus regarding how the two main types of scars hypertrophic and keloidal – are defined. Historically, "we’ve said that hypertrophic scars don’t go beyond the boundary of where the scar tissue was, and keloidal scars go around the perimeter of where the scar boundaries were," he noted. "If the scar is red, even if it’s longstanding, I tend to call it a hypertrophic scar. If it tends to be more flesh colored, and aged like a fine wine, I tend to call it a keloidal scar. The critical thing with these scars is how long it takes the wound to heal. If an open wound takes more than 3-4 weeks to heal, often it will be hypertrophic."

Existing therapies that are commonly used to treat scars include intralesional steroids, intralesional 5-fluorouracil, oral antihistamines, cyclooxygenase-2 inhibitors, lasers, hydrogel sheeting, and compression. "The critical thing is to treat relatively early; you have to use all the weapons that are available to you," Dr. Ross said at the meeting, which was sponsored by the University of California San Diego School of Medicine and the Scripps Clinic.

He said that when treating scars, a modifiable approach should be taken. "You want to modify the scar. After it’s formed, you want to rehabilitate the scar and make it more like the skin around it."

When using intralesional steroids, Dr. Ross prefers to use very low volumes with a very high concentration of Kenalog, "typically 40 mg/mL in tiny amounts with a 3-gauge, half-inch needle," he said. "You want to keep the needle tip relatively superficial. If the steroid floats into the scar too easily you’re probably too deep or under the scar."

He favors using fractional lasers for scars whenever possible. These devices "create microscopic wounds in the skin," he said. "It turns out that if you fractionate a wound, the reservoirs of normal, undamaged skin act as ‘seeds’ to make the wounds heal quickly. I like to use purpuric settings with the pulsed-dye laser. They tend to give you better results than other settings."

For scars that form after thyroid surgery, Dr. Ross likes to use a PDL or IPL (intense pulsed light) to reduce the redness, followed by a nonablative fractional laser. With that tandem approach "you can almost make the scar go away, which is a complete rehabilitation of the scar," he said.

Innovative scar therapies include topical mitomycin C, which has worked well for postoperative keloids; oral and topical tamoxifen, which helps in the formation of fibroblasts; and oral methotrexate, which has demonstrated efficacy in the treatment and prevention of keloids. Imiquimod has also been used, "but I’m not a believer in it," Dr. Ross said. "We’ve tried it several times and we found that it irritated the skin most of the time. Retinoids are good and bad. They decrease fibroblast activity but also decrease collagenase."

Dr. Ross disclosed that he is a consultant for Cutera, Palomar Medical Technologies, and Lumenis. He has also received research support from Palomar, Sciton, and Syneron Medical.

DANA POINT, CALIF. – No longer just a pipe dream, a novel injectable treatment effective at reducing fat is approaching the end of the drug development process.

The product is a non–animal derived, pharmaceutical grade sodium deoxycholate that "acts much like a detergent. It attacks the cell membranes of fat, disrupting and disintegrating its membranes. Thereafter, fat cell contents are released and the subsequent host response, including inflammation, macrophage scavenging, and subclinical fibrosis, may confer a long-lasting fat-removal effect. It doesn’t shrink the fat cell; it ablates the fat it encounters," said, Dr. Adam M. Rotunda.

Phase III trials of an injectable form of sodium deoxycholate for the reduction of submental fat have begun in the United States, building on the previous success of four phase I, three phase II, and two phase III European studies of the product, known as ATX-101, noted Dr. Rotunda at the Summit in Aesthetic Medicine sponsored by the Skin Disease Education Foundation (SDEF).

In the 1990s, compounded phosphatidylcholine/deoxycholate injections (PC/DC), or lipodissolve, caused harm to some patients because "essentially everything about that experience was wrong: the wrong dose (too much volume, too high concentration); wrong depth (injections at times were too superficial. For example, cellulite, which was erroneously believed to improve from the injections, was injected intradermally); wrong indication (injections in places that shouldn’t have been injected); and wrong formulation," said Dr. Rotunda, who practices dermatology in Newport Beach, Calif. "These compounds were [derived] from animal sources and their sterility and purity could be called into question."

As a result, the FDA and other regulatory agencies around the world warned against or banned the use of unapproved PC/DC for aesthetic purposes. But in 2003, sodium deoxycholate was identified as the major component producing fat cell lysis in compounded PC/DC formulations, said Dr. Rotunda, who is also with the department of dermatology at the University of California, Los Angeles. "It’s taken many years to get that message across," he said.

ATX-101, which is being developed by Kythera Biopharmaceuticals, "is very different from the DC in compounded formulations, which was derived from cow bile," he said. "ATX-101 is being studied for very small volumes of fat relatively small for the submental area, which is really an ideal area to observe the desired effect of this product."

Photos courtesy Kythera

Phase I histology studies revealed that ATX-101 causes rapid adipocytolysis on day 1. On day 28 "there’s septal thickening and macrophage infiltration, which removes cellular debris and triglycerides, cleared via the lymphatic system," Dr. Rotunda said, adding that before and after MRIs have quantitatively confirmed the volume reductions.

Tissue surrounding the fatty treatment area, he continued, "has relatively high protein content. This protein (such as albumin) binds and inactivates deoxycholate, making subcutaneous injections relatively safe and fat specific. There’s an inverse relationship: the higher the protein content of certain tissue, such as muscle, tendon, and dermis, the lower the lytic activity of the deoxycholate. Less activity means less damage to that tissue. In fat, however, we want maximal damage, and it works out well because fat has relatively low protein content."

The administration of ATX-101 involves the use of a 30g needle, a 1-mL syringe, and placement of a temporary tattoo grid to the submental fat to control spacing of injections. "The distribution of the grid and how much is injected depends on the patient’s configuration and neck fat volume," Dr. Rotunda said. During the clinical trials, up to 10 mL of medication was used in each session, with up to four monthly treatments.

Most adverse events in clinical trials to date have been mild to moderate. "This is not a lunchtime procedure," he said. "It will be associated with local swelling and tenderness that may last days to several weeks, depending on the amount of ATX-101 injected or the volume of fat treated."

He concluded his remarks by noting that ATX-101 may become a novel approach that complements but does not compete with other fat-reduction therapies.

Dr. Rotunda disclosed that he, along with Dr. Michael S. Kolodney, are coinventors of ATX-101. He is a consultant to Kythera and holds stock in the company. He also is a consultant to Lithera and Allergan.

SDEF and this news organization are owned by Elsevier.

DANA POINT, CALIF. – No longer just a pipe dream, a novel injectable treatment effective at reducing fat is approaching the end of the drug development process.

The product is a non–animal derived, pharmaceutical grade sodium deoxycholate that "acts much like a detergent. It attacks the cell membranes of fat, disrupting and disintegrating its membranes. Thereafter, fat cell contents are released and the subsequent host response, including inflammation, macrophage scavenging, and subclinical fibrosis, may confer a long-lasting fat-removal effect. It doesn’t shrink the fat cell; it ablates the fat it encounters," said, Dr. Adam M. Rotunda.

Phase III trials of an injectable form of sodium deoxycholate for the reduction of submental fat have begun in the United States, building on the previous success of four phase I, three phase II, and two phase III European studies of the product, known as ATX-101, noted Dr. Rotunda at the Summit in Aesthetic Medicine sponsored by the Skin Disease Education Foundation (SDEF).

In the 1990s, compounded phosphatidylcholine/deoxycholate injections (PC/DC), or lipodissolve, caused harm to some patients because "essentially everything about that experience was wrong: the wrong dose (too much volume, too high concentration); wrong depth (injections at times were too superficial. For example, cellulite, which was erroneously believed to improve from the injections, was injected intradermally); wrong indication (injections in places that shouldn’t have been injected); and wrong formulation," said Dr. Rotunda, who practices dermatology in Newport Beach, Calif. "These compounds were [derived] from animal sources and their sterility and purity could be called into question."

As a result, the FDA and other regulatory agencies around the world warned against or banned the use of unapproved PC/DC for aesthetic purposes. But in 2003, sodium deoxycholate was identified as the major component producing fat cell lysis in compounded PC/DC formulations, said Dr. Rotunda, who is also with the department of dermatology at the University of California, Los Angeles. "It’s taken many years to get that message across," he said.

ATX-101, which is being developed by Kythera Biopharmaceuticals, "is very different from the DC in compounded formulations, which was derived from cow bile," he said. "ATX-101 is being studied for very small volumes of fat relatively small for the submental area, which is really an ideal area to observe the desired effect of this product."

Photos courtesy Kythera

Phase I histology studies revealed that ATX-101 causes rapid adipocytolysis on day 1. On day 28 "there’s septal thickening and macrophage infiltration, which removes cellular debris and triglycerides, cleared via the lymphatic system," Dr. Rotunda said, adding that before and after MRIs have quantitatively confirmed the volume reductions.

Tissue surrounding the fatty treatment area, he continued, "has relatively high protein content. This protein (such as albumin) binds and inactivates deoxycholate, making subcutaneous injections relatively safe and fat specific. There’s an inverse relationship: the higher the protein content of certain tissue, such as muscle, tendon, and dermis, the lower the lytic activity of the deoxycholate. Less activity means less damage to that tissue. In fat, however, we want maximal damage, and it works out well because fat has relatively low protein content."

The administration of ATX-101 involves the use of a 30g needle, a 1-mL syringe, and placement of a temporary tattoo grid to the submental fat to control spacing of injections. "The distribution of the grid and how much is injected depends on the patient’s configuration and neck fat volume," Dr. Rotunda said. During the clinical trials, up to 10 mL of medication was used in each session, with up to four monthly treatments.

Most adverse events in clinical trials to date have been mild to moderate. "This is not a lunchtime procedure," he said. "It will be associated with local swelling and tenderness that may last days to several weeks, depending on the amount of ATX-101 injected or the volume of fat treated."

He concluded his remarks by noting that ATX-101 may become a novel approach that complements but does not compete with other fat-reduction therapies.

Dr. Rotunda disclosed that he, along with Dr. Michael S. Kolodney, are coinventors of ATX-101. He is a consultant to Kythera and holds stock in the company. He also is a consultant to Lithera and Allergan.

SDEF and this news organization are owned by Elsevier.

DANA POINT, CALIF. – No longer just a pipe dream, a novel injectable treatment effective at reducing fat is approaching the end of the drug development process.

The product is a non–animal derived, pharmaceutical grade sodium deoxycholate that "acts much like a detergent. It attacks the cell membranes of fat, disrupting and disintegrating its membranes. Thereafter, fat cell contents are released and the subsequent host response, including inflammation, macrophage scavenging, and subclinical fibrosis, may confer a long-lasting fat-removal effect. It doesn’t shrink the fat cell; it ablates the fat it encounters," said, Dr. Adam M. Rotunda.

Phase III trials of an injectable form of sodium deoxycholate for the reduction of submental fat have begun in the United States, building on the previous success of four phase I, three phase II, and two phase III European studies of the product, known as ATX-101, noted Dr. Rotunda at the Summit in Aesthetic Medicine sponsored by the Skin Disease Education Foundation (SDEF).

In the 1990s, compounded phosphatidylcholine/deoxycholate injections (PC/DC), or lipodissolve, caused harm to some patients because "essentially everything about that experience was wrong: the wrong dose (too much volume, too high concentration); wrong depth (injections at times were too superficial. For example, cellulite, which was erroneously believed to improve from the injections, was injected intradermally); wrong indication (injections in places that shouldn’t have been injected); and wrong formulation," said Dr. Rotunda, who practices dermatology in Newport Beach, Calif. "These compounds were [derived] from animal sources and their sterility and purity could be called into question."

As a result, the FDA and other regulatory agencies around the world warned against or banned the use of unapproved PC/DC for aesthetic purposes. But in 2003, sodium deoxycholate was identified as the major component producing fat cell lysis in compounded PC/DC formulations, said Dr. Rotunda, who is also with the department of dermatology at the University of California, Los Angeles. "It’s taken many years to get that message across," he said.

ATX-101, which is being developed by Kythera Biopharmaceuticals, "is very different from the DC in compounded formulations, which was derived from cow bile," he said. "ATX-101 is being studied for very small volumes of fat relatively small for the submental area, which is really an ideal area to observe the desired effect of this product."

Photos courtesy Kythera

Phase I histology studies revealed that ATX-101 causes rapid adipocytolysis on day 1. On day 28 "there’s septal thickening and macrophage infiltration, which removes cellular debris and triglycerides, cleared via the lymphatic system," Dr. Rotunda said, adding that before and after MRIs have quantitatively confirmed the volume reductions.

Tissue surrounding the fatty treatment area, he continued, "has relatively high protein content. This protein (such as albumin) binds and inactivates deoxycholate, making subcutaneous injections relatively safe and fat specific. There’s an inverse relationship: the higher the protein content of certain tissue, such as muscle, tendon, and dermis, the lower the lytic activity of the deoxycholate. Less activity means less damage to that tissue. In fat, however, we want maximal damage, and it works out well because fat has relatively low protein content."

The administration of ATX-101 involves the use of a 30g needle, a 1-mL syringe, and placement of a temporary tattoo grid to the submental fat to control spacing of injections. "The distribution of the grid and how much is injected depends on the patient’s configuration and neck fat volume," Dr. Rotunda said. During the clinical trials, up to 10 mL of medication was used in each session, with up to four monthly treatments.

Most adverse events in clinical trials to date have been mild to moderate. "This is not a lunchtime procedure," he said. "It will be associated with local swelling and tenderness that may last days to several weeks, depending on the amount of ATX-101 injected or the volume of fat treated."

He concluded his remarks by noting that ATX-101 may become a novel approach that complements but does not compete with other fat-reduction therapies.

Dr. Rotunda disclosed that he, along with Dr. Michael S. Kolodney, are coinventors of ATX-101. He is a consultant to Kythera and holds stock in the company. He also is a consultant to Lithera and Allergan.

SDEF and this news organization are owned by Elsevier.

MIAMI BEACH – Adolescents who undergo elective plastic surgery tend to "sail through surgery more easily" than adults, according to an expert.

In addition, more male teenagers seek these procedures, meaning the gender disparity is not as striking as it is among adults.

"When we do cosmetic surgery in teenagers, it is remarkably conflict free, compared with other medical interventions in teenagers, and compared with other age groups," Dr. Mary H. McGrath said. The reasons are not entirely clear – most research in adolescents addresses rhinoplasty only – but it could be because surgery comes during a time of great overall change for teenagers, she said.

Of the estimated 9.2 million surgical and nonsurgical cosmetic procedures in the United States in 2011, 18% were surgical and accounted for 63% of expenditures, according to data from the American Society for Aesthetic Plastic Surgery. Patients 18 years and younger comprised 1.4% of this total and underwent 97,214 nonsurgical and 34,663 surgical procedures.

Otoplasty was the most common 2011 elective surgical procedure in patients under the age of 18 years in 2011. About one third, 34%, of the estimated 11,000 otoplasties were performed on males. Rhinoplasty came in second on the list, with 20% of the 9,500 procedures performed in males. Breast augmentation, liposuction, and breast reduction (for cosmetic reasons) were the next most common, in order, followed by correction of gynecomastia (not surprisingly, 100% in males).

In contrast, in adult patients, more than 90% of all elective plastic surgeries are performed in women, Dr. McGrath said.

Assessment of physical and mental health is the first step when an adolescent asks about plastic surgery in the primary care setting, Dr. McGrath said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Ensure the adolescent has the necessary emotional and physical maturity. "Determine that the patient has reached the growth milestone and physical maturity for that surgery. We wouldn’t do breast augmentation on a 16-year-old," for example, said Dr. McGrath, professor of surgery in the division of plastic and reconstructive surgery at the University of California, San Francisco. Also rule out any psychiatric contraindication, such as body dysmorphic disorder, she said.

Speak with the patient alone. Also talk with them with their family present to assess the degree of support. Ask the patient to articulate why they want the surgery. Ensure patient expectations are realistic. After referral, a plastic surgeon ideally will assess the specific deficit, outline what can be accomplished surgically, and describe the potential risks. Efficacy and safety considerations are critical, Dr. McGrath said.

Ask teenagers to explain how they would handle a complication. Dr. McGrath also asks them to repeat back important aspects of the discussion to ensure they understand.

Dr. McGrath shared some tips and insight on the following procedures:

• Otoplasty. The ear achieves 85% of full growth by age 3 years, which is "why kids’ ears look so big." Sometimes, the goal of surgery is to approximate symmetry. A good plastic surgeon will be familiar with the subtle anatomic features of the ear: the top of the ear is generally closer to the head than the middle, while the lobule at the bottom should stick out the most.

Otoplasty is usually an outpatient procedure. Patients can expect a bulky head dressing postoperatively, suture removal after 7-10 days, and to sleep with an elastic band around their head for 2-3 weeks. Hematoma and infection are potential early complications and residual deformity or asymmetry can emerge later. An estimated 8%-10% of patients undergo reoperations, almost always for asymmetry, Dr. McGrath said.

• Rhinoplasty. "Very rarely do we do rhinoplasty in someone younger than 17 or 18 [years old] or they can outgrow the changes in nasal contour," Dr. McGrath said. "Sometimes, I feel bad telling a 14-year-old with an exceptionally large or unattractive nose they have to wait and come back at age 17."

Prepare teenage patients for the postoperative course by showing them photos of typical patients. Tell them to expect splinting for 7 days, ecchymosis for 10-14 days, and residual swelling for 2-3 months. Postoperative changes become quickly obvious after a bony ridge removal. In contrast, a nasal tip rhinoplasty, because it involves soft tissue and more edema, can take months to see the final result.

"This is the hardest surgery we do," Dr. McGrath said. "It is complicated to understand all the pieces of the puzzle and get it right. It requires the greatest amount of art." The most common complication is bleeding in about 4% of patients.

• Breast Augmentation. Only a small minority of breast augmentation procedures, 1.5%, were performed in patients 18 years and younger in 2011. "Young women seek breast implants because their breasts look odd; it is not necessarily size that is driving it, but almost always the shape," Dr. McGrath said.

Approximately 25% of patients having breast augmentation have a reoperation within 10 years. "That is the number to know," Dr. McGrath said. "Is the likelihood of additional surgery acceptable to the patient?"

Silicone breast implants are not FDA cleared for breast reconstruction in females younger than 22 years. Therefore, only saline implants are an option in these younger patients, Dr. McGrath said. An advantage of saline implants is they can be inserted through a small incision and then filled, which is not possible with silicone gel implants.

Pain, hematoma, seroma, wound infection, and decreased skin sensation are potential complications. However, "the problems due to the implantable device are the real issues," Dr. McGrath said. Scarring can occur around 15% of implants; 8% or 9% can become malpositioned and about 7% will deflate over 5 years. In addition, patients with a family history of breast cancer may choose not to have implants.

Consultation with a qualified plastic surgeon who can focus on long-term implications is warranted, Dr. McGrath said.

• Breast Reduction. Defer surgery until full breast maturation and growth is achieved. Breast size should be stable with no continuing growth for 9-12 months, Dr. McGrath said.

Smoking, obesity, medical conditions that impair wound healing, bleeding disorders, or a body mass index greater than 30 kg/m² are contraindications. "Some obese women have large breasts, and many are disappointed when I tell them they should defer breast reduction until after weight loss."

Another point to counsel patients about is that lactation is not always possible after breast reduction. "I have had young women walk away from this and say, ‘It’s very important for me to breast feed my baby someday.’"

• Liposuction. The American Society of Plastic Surgeons cautions that liposuction and tummy tucks are inappropriate procedures for weight loss in teens, Dr. McGrath said. "I cannot tell you how many obese teens get referred to me for liposuction. I have to tell them it’s not the right thing ... and it will not correct your basic problem."

In contrast, lipoplasty, liposculpture, or liposuction to treat localized fat deposits can be indicated in some teenagers. "The ideal patient is at or near ideal body weight with elastic skin that will retract."

"Submental liposuction of the fat pad creating a double chin in older teenagers can be fantastic," Dr. McGrath said. It can be done in an office setting. Bruising, seroma, and bumpy appearance are potential complications. Instruct patients that they will have to wear a compression garment around their head at night for about 3 weeks.

• Gynecomastia. About 8% of all gynecomastia corrections involved patients 18 years and younger. Approximately 50% are unilateral and 50% bilateral procedures.

Gynecomastia can have a hormonal etiology and be associated with obesity. Surgical results, however, are poorer in the obese patient. "The distinction between what is gynecomastia and fat tissue gets murky in overweight patients," Dr. McGrath said.

Gynecomastia can be self-limited with an average duration of 1-2 years. For those in whom it persists, some seek surgery because "it is a source of embarrassment. Like our young women, it’s not so much the size, it’s the odd look of a protuberant breast on a male."

"The central issue with any elective plastic surgery is not the presence or absence of disease, rather the effect of the problem on the person," Dr. McGrath said. "It comes down to quality of life, and whether or not you believe improving quality of life is part of our job."

Dr. McGrath recommended the American Society for Aesthetic Plastic Surgery guidelines for evaluating teenagers considering cosmetic plastic surgery.

Dr. McGrath said she had no relevant financial disclosures.

MIAMI BEACH – Adolescents who undergo elective plastic surgery tend to "sail through surgery more easily" than adults, according to an expert.

In addition, more male teenagers seek these procedures, meaning the gender disparity is not as striking as it is among adults.

"When we do cosmetic surgery in teenagers, it is remarkably conflict free, compared with other medical interventions in teenagers, and compared with other age groups," Dr. Mary H. McGrath said. The reasons are not entirely clear – most research in adolescents addresses rhinoplasty only – but it could be because surgery comes during a time of great overall change for teenagers, she said.

Of the estimated 9.2 million surgical and nonsurgical cosmetic procedures in the United States in 2011, 18% were surgical and accounted for 63% of expenditures, according to data from the American Society for Aesthetic Plastic Surgery. Patients 18 years and younger comprised 1.4% of this total and underwent 97,214 nonsurgical and 34,663 surgical procedures.

Otoplasty was the most common 2011 elective surgical procedure in patients under the age of 18 years in 2011. About one third, 34%, of the estimated 11,000 otoplasties were performed on males. Rhinoplasty came in second on the list, with 20% of the 9,500 procedures performed in males. Breast augmentation, liposuction, and breast reduction (for cosmetic reasons) were the next most common, in order, followed by correction of gynecomastia (not surprisingly, 100% in males).

In contrast, in adult patients, more than 90% of all elective plastic surgeries are performed in women, Dr. McGrath said.

Assessment of physical and mental health is the first step when an adolescent asks about plastic surgery in the primary care setting, Dr. McGrath said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Ensure the adolescent has the necessary emotional and physical maturity. "Determine that the patient has reached the growth milestone and physical maturity for that surgery. We wouldn’t do breast augmentation on a 16-year-old," for example, said Dr. McGrath, professor of surgery in the division of plastic and reconstructive surgery at the University of California, San Francisco. Also rule out any psychiatric contraindication, such as body dysmorphic disorder, she said.

Speak with the patient alone. Also talk with them with their family present to assess the degree of support. Ask the patient to articulate why they want the surgery. Ensure patient expectations are realistic. After referral, a plastic surgeon ideally will assess the specific deficit, outline what can be accomplished surgically, and describe the potential risks. Efficacy and safety considerations are critical, Dr. McGrath said.

Ask teenagers to explain how they would handle a complication. Dr. McGrath also asks them to repeat back important aspects of the discussion to ensure they understand.

Dr. McGrath shared some tips and insight on the following procedures:

• Otoplasty. The ear achieves 85% of full growth by age 3 years, which is "why kids’ ears look so big." Sometimes, the goal of surgery is to approximate symmetry. A good plastic surgeon will be familiar with the subtle anatomic features of the ear: the top of the ear is generally closer to the head than the middle, while the lobule at the bottom should stick out the most.

Otoplasty is usually an outpatient procedure. Patients can expect a bulky head dressing postoperatively, suture removal after 7-10 days, and to sleep with an elastic band around their head for 2-3 weeks. Hematoma and infection are potential early complications and residual deformity or asymmetry can emerge later. An estimated 8%-10% of patients undergo reoperations, almost always for asymmetry, Dr. McGrath said.

• Rhinoplasty. "Very rarely do we do rhinoplasty in someone younger than 17 or 18 [years old] or they can outgrow the changes in nasal contour," Dr. McGrath said. "Sometimes, I feel bad telling a 14-year-old with an exceptionally large or unattractive nose they have to wait and come back at age 17."

Prepare teenage patients for the postoperative course by showing them photos of typical patients. Tell them to expect splinting for 7 days, ecchymosis for 10-14 days, and residual swelling for 2-3 months. Postoperative changes become quickly obvious after a bony ridge removal. In contrast, a nasal tip rhinoplasty, because it involves soft tissue and more edema, can take months to see the final result.

"This is the hardest surgery we do," Dr. McGrath said. "It is complicated to understand all the pieces of the puzzle and get it right. It requires the greatest amount of art." The most common complication is bleeding in about 4% of patients.

• Breast Augmentation. Only a small minority of breast augmentation procedures, 1.5%, were performed in patients 18 years and younger in 2011. "Young women seek breast implants because their breasts look odd; it is not necessarily size that is driving it, but almost always the shape," Dr. McGrath said.

Approximately 25% of patients having breast augmentation have a reoperation within 10 years. "That is the number to know," Dr. McGrath said. "Is the likelihood of additional surgery acceptable to the patient?"

Silicone breast implants are not FDA cleared for breast reconstruction in females younger than 22 years. Therefore, only saline implants are an option in these younger patients, Dr. McGrath said. An advantage of saline implants is they can be inserted through a small incision and then filled, which is not possible with silicone gel implants.

Pain, hematoma, seroma, wound infection, and decreased skin sensation are potential complications. However, "the problems due to the implantable device are the real issues," Dr. McGrath said. Scarring can occur around 15% of implants; 8% or 9% can become malpositioned and about 7% will deflate over 5 years. In addition, patients with a family history of breast cancer may choose not to have implants.

Consultation with a qualified plastic surgeon who can focus on long-term implications is warranted, Dr. McGrath said.

• Breast Reduction. Defer surgery until full breast maturation and growth is achieved. Breast size should be stable with no continuing growth for 9-12 months, Dr. McGrath said.

Smoking, obesity, medical conditions that impair wound healing, bleeding disorders, or a body mass index greater than 30 kg/m² are contraindications. "Some obese women have large breasts, and many are disappointed when I tell them they should defer breast reduction until after weight loss."

Another point to counsel patients about is that lactation is not always possible after breast reduction. "I have had young women walk away from this and say, ‘It’s very important for me to breast feed my baby someday.’"

• Liposuction. The American Society of Plastic Surgeons cautions that liposuction and tummy tucks are inappropriate procedures for weight loss in teens, Dr. McGrath said. "I cannot tell you how many obese teens get referred to me for liposuction. I have to tell them it’s not the right thing ... and it will not correct your basic problem."

In contrast, lipoplasty, liposculpture, or liposuction to treat localized fat deposits can be indicated in some teenagers. "The ideal patient is at or near ideal body weight with elastic skin that will retract."

"Submental liposuction of the fat pad creating a double chin in older teenagers can be fantastic," Dr. McGrath said. It can be done in an office setting. Bruising, seroma, and bumpy appearance are potential complications. Instruct patients that they will have to wear a compression garment around their head at night for about 3 weeks.

• Gynecomastia. About 8% of all gynecomastia corrections involved patients 18 years and younger. Approximately 50% are unilateral and 50% bilateral procedures.

Gynecomastia can have a hormonal etiology and be associated with obesity. Surgical results, however, are poorer in the obese patient. "The distinction between what is gynecomastia and fat tissue gets murky in overweight patients," Dr. McGrath said.

Gynecomastia can be self-limited with an average duration of 1-2 years. For those in whom it persists, some seek surgery because "it is a source of embarrassment. Like our young women, it’s not so much the size, it’s the odd look of a protuberant breast on a male."

"The central issue with any elective plastic surgery is not the presence or absence of disease, rather the effect of the problem on the person," Dr. McGrath said. "It comes down to quality of life, and whether or not you believe improving quality of life is part of our job."

Dr. McGrath recommended the American Society for Aesthetic Plastic Surgery guidelines for evaluating teenagers considering cosmetic plastic surgery.

Dr. McGrath said she had no relevant financial disclosures.

MIAMI BEACH – Adolescents who undergo elective plastic surgery tend to "sail through surgery more easily" than adults, according to an expert.

In addition, more male teenagers seek these procedures, meaning the gender disparity is not as striking as it is among adults.

"When we do cosmetic surgery in teenagers, it is remarkably conflict free, compared with other medical interventions in teenagers, and compared with other age groups," Dr. Mary H. McGrath said. The reasons are not entirely clear – most research in adolescents addresses rhinoplasty only – but it could be because surgery comes during a time of great overall change for teenagers, she said.

Of the estimated 9.2 million surgical and nonsurgical cosmetic procedures in the United States in 2011, 18% were surgical and accounted for 63% of expenditures, according to data from the American Society for Aesthetic Plastic Surgery. Patients 18 years and younger comprised 1.4% of this total and underwent 97,214 nonsurgical and 34,663 surgical procedures.

Otoplasty was the most common 2011 elective surgical procedure in patients under the age of 18 years in 2011. About one third, 34%, of the estimated 11,000 otoplasties were performed on males. Rhinoplasty came in second on the list, with 20% of the 9,500 procedures performed in males. Breast augmentation, liposuction, and breast reduction (for cosmetic reasons) were the next most common, in order, followed by correction of gynecomastia (not surprisingly, 100% in males).

In contrast, in adult patients, more than 90% of all elective plastic surgeries are performed in women, Dr. McGrath said.

Assessment of physical and mental health is the first step when an adolescent asks about plastic surgery in the primary care setting, Dr. McGrath said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Ensure the adolescent has the necessary emotional and physical maturity. "Determine that the patient has reached the growth milestone and physical maturity for that surgery. We wouldn’t do breast augmentation on a 16-year-old," for example, said Dr. McGrath, professor of surgery in the division of plastic and reconstructive surgery at the University of California, San Francisco. Also rule out any psychiatric contraindication, such as body dysmorphic disorder, she said.

Speak with the patient alone. Also talk with them with their family present to assess the degree of support. Ask the patient to articulate why they want the surgery. Ensure patient expectations are realistic. After referral, a plastic surgeon ideally will assess the specific deficit, outline what can be accomplished surgically, and describe the potential risks. Efficacy and safety considerations are critical, Dr. McGrath said.

Ask teenagers to explain how they would handle a complication. Dr. McGrath also asks them to repeat back important aspects of the discussion to ensure they understand.

Dr. McGrath shared some tips and insight on the following procedures:

• Otoplasty. The ear achieves 85% of full growth by age 3 years, which is "why kids’ ears look so big." Sometimes, the goal of surgery is to approximate symmetry. A good plastic surgeon will be familiar with the subtle anatomic features of the ear: the top of the ear is generally closer to the head than the middle, while the lobule at the bottom should stick out the most.

Otoplasty is usually an outpatient procedure. Patients can expect a bulky head dressing postoperatively, suture removal after 7-10 days, and to sleep with an elastic band around their head for 2-3 weeks. Hematoma and infection are potential early complications and residual deformity or asymmetry can emerge later. An estimated 8%-10% of patients undergo reoperations, almost always for asymmetry, Dr. McGrath said.

• Rhinoplasty. "Very rarely do we do rhinoplasty in someone younger than 17 or 18 [years old] or they can outgrow the changes in nasal contour," Dr. McGrath said. "Sometimes, I feel bad telling a 14-year-old with an exceptionally large or unattractive nose they have to wait and come back at age 17."

Prepare teenage patients for the postoperative course by showing them photos of typical patients. Tell them to expect splinting for 7 days, ecchymosis for 10-14 days, and residual swelling for 2-3 months. Postoperative changes become quickly obvious after a bony ridge removal. In contrast, a nasal tip rhinoplasty, because it involves soft tissue and more edema, can take months to see the final result.

"This is the hardest surgery we do," Dr. McGrath said. "It is complicated to understand all the pieces of the puzzle and get it right. It requires the greatest amount of art." The most common complication is bleeding in about 4% of patients.

• Breast Augmentation. Only a small minority of breast augmentation procedures, 1.5%, were performed in patients 18 years and younger in 2011. "Young women seek breast implants because their breasts look odd; it is not necessarily size that is driving it, but almost always the shape," Dr. McGrath said.

Approximately 25% of patients having breast augmentation have a reoperation within 10 years. "That is the number to know," Dr. McGrath said. "Is the likelihood of additional surgery acceptable to the patient?"

Silicone breast implants are not FDA cleared for breast reconstruction in females younger than 22 years. Therefore, only saline implants are an option in these younger patients, Dr. McGrath said. An advantage of saline implants is they can be inserted through a small incision and then filled, which is not possible with silicone gel implants.

Pain, hematoma, seroma, wound infection, and decreased skin sensation are potential complications. However, "the problems due to the implantable device are the real issues," Dr. McGrath said. Scarring can occur around 15% of implants; 8% or 9% can become malpositioned and about 7% will deflate over 5 years. In addition, patients with a family history of breast cancer may choose not to have implants.

Consultation with a qualified plastic surgeon who can focus on long-term implications is warranted, Dr. McGrath said.

• Breast Reduction. Defer surgery until full breast maturation and growth is achieved. Breast size should be stable with no continuing growth for 9-12 months, Dr. McGrath said.

Smoking, obesity, medical conditions that impair wound healing, bleeding disorders, or a body mass index greater than 30 kg/m² are contraindications. "Some obese women have large breasts, and many are disappointed when I tell them they should defer breast reduction until after weight loss."

Another point to counsel patients about is that lactation is not always possible after breast reduction. "I have had young women walk away from this and say, ‘It’s very important for me to breast feed my baby someday.’"

• Liposuction. The American Society of Plastic Surgeons cautions that liposuction and tummy tucks are inappropriate procedures for weight loss in teens, Dr. McGrath said. "I cannot tell you how many obese teens get referred to me for liposuction. I have to tell them it’s not the right thing ... and it will not correct your basic problem."

In contrast, lipoplasty, liposculpture, or liposuction to treat localized fat deposits can be indicated in some teenagers. "The ideal patient is at or near ideal body weight with elastic skin that will retract."

"Submental liposuction of the fat pad creating a double chin in older teenagers can be fantastic," Dr. McGrath said. It can be done in an office setting. Bruising, seroma, and bumpy appearance are potential complications. Instruct patients that they will have to wear a compression garment around their head at night for about 3 weeks.

• Gynecomastia. About 8% of all gynecomastia corrections involved patients 18 years and younger. Approximately 50% are unilateral and 50% bilateral procedures.

Gynecomastia can have a hormonal etiology and be associated with obesity. Surgical results, however, are poorer in the obese patient. "The distinction between what is gynecomastia and fat tissue gets murky in overweight patients," Dr. McGrath said.

Gynecomastia can be self-limited with an average duration of 1-2 years. For those in whom it persists, some seek surgery because "it is a source of embarrassment. Like our young women, it’s not so much the size, it’s the odd look of a protuberant breast on a male."

"The central issue with any elective plastic surgery is not the presence or absence of disease, rather the effect of the problem on the person," Dr. McGrath said. "It comes down to quality of life, and whether or not you believe improving quality of life is part of our job."

Dr. McGrath recommended the American Society for Aesthetic Plastic Surgery guidelines for evaluating teenagers considering cosmetic plastic surgery.

Dr. McGrath said she had no relevant financial disclosures.

Before-and-after photographs are the stock in trade of house painters, auto repair shops, and, yes, plastic and reconstructive surgeons. But a new study may make the last group pause, since it hints that far more is at play in breast cancer patients’ definition of “successful’’ breast reconstruction surgery than how their breasts appear.

The study from Liverpool, England (J Plast Reconstr Aesthet Surg (2012): doi:10.1016/j.bjps.2012.03.005) sidestepped traditional measures used to evaluate outcomes of aesthetic breast surgery and instead asked open-ended questions of survivors who had undergone reconstruction 1-8 years previously.

What the researchers discovered, not surprisingly, is that reconstruction patients are quite unlike cosmetic surgery patients in fundamental and important ways.

©Lilli Day/iStockphoto.com

Of particular interest in the initial study cohort of 95 patients were 38 whose subjective evaluations of their surgical results completely contradicted objective ratings of cosmesis, the final appearance of the reconstructed breast(s) by surgeons and surgical nurses.

Incredibly, the association between women’s assessments and objective cosmesis ratings failed even to reach statistical significance.

In a structured data analysis of themes that arose in open-ended interviews with 27 of the survivors, the strongest link to women’s satisfaction with the procedure was the surgeon-patient relationship.

Next came the significance of reconstruction in what patients saw as the “completion of the cancer journey,” the authors wrote. “Patients who focused on this were positive about reconstruction that practitioners had rated negatively.”

A previous study asked patients about scarring, finding a correlation between scarring and dissatisfaction with reconstruction. But scarring wasn’t even a blip on the radar when, quoting from the Liverpool study, “we allowed patients to tell us what mattered to them rather than imposing our preconceptions.”

“It seems that surgeons and patients normally ‘talk different languages’; one technical and the other drawing more from relationships and patients’ sense of how normal they feel and appear and from their sense that reconstruction completes their cancer journey,” the investigators concluded. “In preoperative consultations, surgeons concentrate almost exclusively on the technical and cosmetic aspects of reconstruction: what can be achieved and what complications can occur.”

Of course, women who struggled with complications tended to factor that in to their assessments of their results, even if their final cosmetic outcome was considered by surgeons to be excellent.

Others were disappointed despite what seemed to surgeons to be  excellent cosmetic results because, as one said, “I was expecting to feel feminine again, but I don’t, I don’t at all.”

What is perhaps even more interesting is to eavesdrop on the comments of women whose surgeons judged their cosmetic result to be poor.

Said one, “I had a really good relationship with (the surgeon) and I just found it so reassuring to see her. That was part of the whole thing really. She was just so positive, and so, well, just understanding I think … I was really glad that I had chosen that form of reconstruction because I had this regular contact with her.”

Said another, who felt “normal” despite what her surgeon considered to be a poor result: “If I didn’t have it done, I wouldn’t have felt normal at all. It would always remind me of what had happened.”

A highly complex patient-surgeon dance occurs when breast surgery is performed for more than cosmetic reasons, the study found.

One woman, disappointed with the way her reconstructed breast fit in a bra, could not bring herself to voice her concern with the surgeon she credited with saving her life.

“It’s very difficult to come face to face with somebody who says, ‘You’ve had cancer but we can get rid of it,’ and does their best… without seeming ungrateful,” she said, tearfully.

The study concludes with a fascinating discussion about the potential clinical implications of the findings.

Considering the profound influence of the patient-surgeon relationship on these particular patients, the investigators offer a cautionary suggestion to avoid being overly effusive about the cosmetic result they may see. Patients, they explain, may not necessarily share their enthusiasm, if they continue to struggle with the sense that cancer has marred their bodies, their sense of self, or their security in relationships.

“Both patient and surgeon have invested physically and emotionally in the procedure and it is difficult for either to admit to the other that it was “not worth it,” they note.

Women, on the other hand, who appear to be disproportionately pleased with the result of surgery that objectively achieved a poor result may simply be expressing relief and gratitude. “Their apparent satisfaction,” they wrote, “should not excuse poor surgical practice.” Rather, routine assessments of reconstructive practice should be made by objective sources, not simply patient report.

On the other hand, in individual patients, the objective in reconstructive surgery is patient satisfaction, they suggest. An unhappy patient might spur a conscientious surgeon to keep trying, perhaps through repeated procedures, to achieve a better result – a strategy that could be inappropriate and pointless considering that in some cases, “the reason for disappointment with reconstruction include many that the surgeon cannot influence surgically.”

It all suggests that communication between surgeons and reconstruction candidates and patients needs to be deep and candidly honest, informed by the emotional, sexual, and existential meaning the surgery holds.

In a word, it’s complicated.

Betsy Bates Freed, Psych.D., is a clinical psychologist in Santa Barbara, Calif., and a medical journalist.

Before-and-after photographs are the stock in trade of house painters, auto repair shops, and, yes, plastic and reconstructive surgeons. But a new study may make the last group pause, since it hints that far more is at play in breast cancer patients’ definition of “successful’’ breast reconstruction surgery than how their breasts appear.

The study from Liverpool, England (J Plast Reconstr Aesthet Surg (2012): doi:10.1016/j.bjps.2012.03.005) sidestepped traditional measures used to evaluate outcomes of aesthetic breast surgery and instead asked open-ended questions of survivors who had undergone reconstruction 1-8 years previously.

What the researchers discovered, not surprisingly, is that reconstruction patients are quite unlike cosmetic surgery patients in fundamental and important ways.

©Lilli Day/iStockphoto.com

Of particular interest in the initial study cohort of 95 patients were 38 whose subjective evaluations of their surgical results completely contradicted objective ratings of cosmesis, the final appearance of the reconstructed breast(s) by surgeons and surgical nurses.

Incredibly, the association between women’s assessments and objective cosmesis ratings failed even to reach statistical significance.

In a structured data analysis of themes that arose in open-ended interviews with 27 of the survivors, the strongest link to women’s satisfaction with the procedure was the surgeon-patient relationship.

Next came the significance of reconstruction in what patients saw as the “completion of the cancer journey,” the authors wrote. “Patients who focused on this were positive about reconstruction that practitioners had rated negatively.”

A previous study asked patients about scarring, finding a correlation between scarring and dissatisfaction with reconstruction. But scarring wasn’t even a blip on the radar when, quoting from the Liverpool study, “we allowed patients to tell us what mattered to them rather than imposing our preconceptions.”

“It seems that surgeons and patients normally ‘talk different languages’; one technical and the other drawing more from relationships and patients’ sense of how normal they feel and appear and from their sense that reconstruction completes their cancer journey,” the investigators concluded. “In preoperative consultations, surgeons concentrate almost exclusively on the technical and cosmetic aspects of reconstruction: what can be achieved and what complications can occur.”

Of course, women who struggled with complications tended to factor that in to their assessments of their results, even if their final cosmetic outcome was considered by surgeons to be excellent.

Others were disappointed despite what seemed to surgeons to be  excellent cosmetic results because, as one said, “I was expecting to feel feminine again, but I don’t, I don’t at all.”

What is perhaps even more interesting is to eavesdrop on the comments of women whose surgeons judged their cosmetic result to be poor.

Said one, “I had a really good relationship with (the surgeon) and I just found it so reassuring to see her. That was part of the whole thing really. She was just so positive, and so, well, just understanding I think … I was really glad that I had chosen that form of reconstruction because I had this regular contact with her.”

Said another, who felt “normal” despite what her surgeon considered to be a poor result: “If I didn’t have it done, I wouldn’t have felt normal at all. It would always remind me of what had happened.”

A highly complex patient-surgeon dance occurs when breast surgery is performed for more than cosmetic reasons, the study found.

One woman, disappointed with the way her reconstructed breast fit in a bra, could not bring herself to voice her concern with the surgeon she credited with saving her life.

“It’s very difficult to come face to face with somebody who says, ‘You’ve had cancer but we can get rid of it,’ and does their best… without seeming ungrateful,” she said, tearfully.

The study concludes with a fascinating discussion about the potential clinical implications of the findings.

Considering the profound influence of the patient-surgeon relationship on these particular patients, the investigators offer a cautionary suggestion to avoid being overly effusive about the cosmetic result they may see. Patients, they explain, may not necessarily share their enthusiasm, if they continue to struggle with the sense that cancer has marred their bodies, their sense of self, or their security in relationships.

“Both patient and surgeon have invested physically and emotionally in the procedure and it is difficult for either to admit to the other that it was “not worth it,” they note.

Women, on the other hand, who appear to be disproportionately pleased with the result of surgery that objectively achieved a poor result may simply be expressing relief and gratitude. “Their apparent satisfaction,” they wrote, “should not excuse poor surgical practice.” Rather, routine assessments of reconstructive practice should be made by objective sources, not simply patient report.

On the other hand, in individual patients, the objective in reconstructive surgery is patient satisfaction, they suggest. An unhappy patient might spur a conscientious surgeon to keep trying, perhaps through repeated procedures, to achieve a better result – a strategy that could be inappropriate and pointless considering that in some cases, “the reason for disappointment with reconstruction include many that the surgeon cannot influence surgically.”

It all suggests that communication between surgeons and reconstruction candidates and patients needs to be deep and candidly honest, informed by the emotional, sexual, and existential meaning the surgery holds.

In a word, it’s complicated.

Betsy Bates Freed, Psych.D., is a clinical psychologist in Santa Barbara, Calif., and a medical journalist.

Before-and-after photographs are the stock in trade of house painters, auto repair shops, and, yes, plastic and reconstructive surgeons. But a new study may make the last group pause, since it hints that far more is at play in breast cancer patients’ definition of “successful’’ breast reconstruction surgery than how their breasts appear.

The study from Liverpool, England (J Plast Reconstr Aesthet Surg (2012): doi:10.1016/j.bjps.2012.03.005) sidestepped traditional measures used to evaluate outcomes of aesthetic breast surgery and instead asked open-ended questions of survivors who had undergone reconstruction 1-8 years previously.

What the researchers discovered, not surprisingly, is that reconstruction patients are quite unlike cosmetic surgery patients in fundamental and important ways.

©Lilli Day/iStockphoto.com

Of particular interest in the initial study cohort of 95 patients were 38 whose subjective evaluations of their surgical results completely contradicted objective ratings of cosmesis, the final appearance of the reconstructed breast(s) by surgeons and surgical nurses.

Incredibly, the association between women’s assessments and objective cosmesis ratings failed even to reach statistical significance.

In a structured data analysis of themes that arose in open-ended interviews with 27 of the survivors, the strongest link to women’s satisfaction with the procedure was the surgeon-patient relationship.

Next came the significance of reconstruction in what patients saw as the “completion of the cancer journey,” the authors wrote. “Patients who focused on this were positive about reconstruction that practitioners had rated negatively.”

A previous study asked patients about scarring, finding a correlation between scarring and dissatisfaction with reconstruction. But scarring wasn’t even a blip on the radar when, quoting from the Liverpool study, “we allowed patients to tell us what mattered to them rather than imposing our preconceptions.”

“It seems that surgeons and patients normally ‘talk different languages’; one technical and the other drawing more from relationships and patients’ sense of how normal they feel and appear and from their sense that reconstruction completes their cancer journey,” the investigators concluded. “In preoperative consultations, surgeons concentrate almost exclusively on the technical and cosmetic aspects of reconstruction: what can be achieved and what complications can occur.”

Of course, women who struggled with complications tended to factor that in to their assessments of their results, even if their final cosmetic outcome was considered by surgeons to be excellent.

Others were disappointed despite what seemed to surgeons to be  excellent cosmetic results because, as one said, “I was expecting to feel feminine again, but I don’t, I don’t at all.”

What is perhaps even more interesting is to eavesdrop on the comments of women whose surgeons judged their cosmetic result to be poor.

Said one, “I had a really good relationship with (the surgeon) and I just found it so reassuring to see her. That was part of the whole thing really. She was just so positive, and so, well, just understanding I think … I was really glad that I had chosen that form of reconstruction because I had this regular contact with her.”

Said another, who felt “normal” despite what her surgeon considered to be a poor result: “If I didn’t have it done, I wouldn’t have felt normal at all. It would always remind me of what had happened.”

A highly complex patient-surgeon dance occurs when breast surgery is performed for more than cosmetic reasons, the study found.

One woman, disappointed with the way her reconstructed breast fit in a bra, could not bring herself to voice her concern with the surgeon she credited with saving her life.

“It’s very difficult to come face to face with somebody who says, ‘You’ve had cancer but we can get rid of it,’ and does their best… without seeming ungrateful,” she said, tearfully.

The study concludes with a fascinating discussion about the potential clinical implications of the findings.

Considering the profound influence of the patient-surgeon relationship on these particular patients, the investigators offer a cautionary suggestion to avoid being overly effusive about the cosmetic result they may see. Patients, they explain, may not necessarily share their enthusiasm, if they continue to struggle with the sense that cancer has marred their bodies, their sense of self, or their security in relationships.

“Both patient and surgeon have invested physically and emotionally in the procedure and it is difficult for either to admit to the other that it was “not worth it,” they note.

Women, on the other hand, who appear to be disproportionately pleased with the result of surgery that objectively achieved a poor result may simply be expressing relief and gratitude. “Their apparent satisfaction,” they wrote, “should not excuse poor surgical practice.” Rather, routine assessments of reconstructive practice should be made by objective sources, not simply patient report.

On the other hand, in individual patients, the objective in reconstructive surgery is patient satisfaction, they suggest. An unhappy patient might spur a conscientious surgeon to keep trying, perhaps through repeated procedures, to achieve a better result – a strategy that could be inappropriate and pointless considering that in some cases, “the reason for disappointment with reconstruction include many that the surgeon cannot influence surgically.”

It all suggests that communication between surgeons and reconstruction candidates and patients needs to be deep and candidly honest, informed by the emotional, sexual, and existential meaning the surgery holds.

In a word, it’s complicated.

Betsy Bates Freed, Psych.D., is a clinical psychologist in Santa Barbara, Calif., and a medical journalist.