Archive for January, 2010

Skin Fillers for Facial Rejuvenation

Wednesday, January 27th, 2010

The dichotomy in the hype of filler products for facial rejuvenation has confused physicians and made intelligent comparisons on the part of the public virtually impossible. In order to understand the confusion in marketing fillers I will divide the protagonists into 2 camps: the manufacturers and salons (medispas) vs. cosmetic surgeons which include sophisticated dermatologists, facial plastic surgeons, plastic surgeons, oral maxillofacial surgeons, and oculoplastic surgeons.
The hype looks like the following:
Manufacturers must sell as much product as possible to maximize profits. In order to increase consumer consumption, marketing revolves around simplistic notions of instant repair such as erasing nasolabial folds- the fold between the sides of the nose and the corners of the mouth and advising frequent re-treatments.
Medispas likewise promote simplistic makeovers which are quickly performed and provide instantaneous results.
These promoters can get away with such obfuscation by exploiting the difference between the forest and the trees. As the saying goes we tend to focus on the trees and not appreciate the forest much as we might not recognizing the elephant in the room.(Kindergarten: How can you tell if there is an elephant in the room. Answer: By the faint odor of peanuts on his breath). A typical patient complains about a line around her mouth and misses the point that her cheeks and eyes are sunken-in which not only causes the line but is the real reason she is looking older. By contrast a child with a scar on her cheek looks youthful and has a scar. (Don’t fall for the “I will just inject filler under your eyes and your circles will go away” either.)
Manufacturers and medi-spas also promote differences in products in order to justify more and less fee schedules for products. They do this primarily by claiming that different products have different longevities which is a concept that is easy for the public to understand. Longer duration of correction should provide lower cost over time and less need to retreat. They conveniently do not explain that in areas of the face with more muscle contraction fillers have shorter duration of action and visa versa. Therefore hyaluronic acid infiltrated into a cheek may last 2 or more years and sculptra may last up to 6 years whereas the same products placed around the mouth may last up to 70% less.
As I have been teaching at MetropolitanMD for the past 10 years rejuvenating eyes, cheeks, and temples not only lasts a relatively long time, the results do make one appear more youthful and healthy. The first step in facial rejuvenation is knowing why one looks older before it is possible to resolve the problem. It is kind of like putting a bigger burger in your sandwich vs. covering it with a larger bun. It’s all in what you want

Grading President Obama After One Year

Monday, January 25th, 2010

President Obama is at least an immensely eloquent and intelligent speaker. At the beginning of his Presidency he outlined a series of goals with which he would initiate his administration of the nation. I propose to grade him in an objective manner based on his productivity and not on whether I agree with his goals.
I. He would create a bipartisan environment in which all factions of the public would be heard and served. One year later- the country has not been more politically divided since perhaps 1840. Hate messages are rampant in chat rooms and Congress is so politicized that members refer to each other in derogatory terms. Whatever this is, it does not represent successful leadership.
II. The President acknowledged the hemorrhaging of the economy and the need for jobs. One year later- not only has the jobless situation intensified, he has failed to initiate an economic stimulus package that emphasized infrastructure and job creation. During the same period of time the Chinese government has done so and their economy is thriving.
III. The President’s main objective was health care reform. One year later - Not only was no legislation passed, under his leadership the Republican party has become the party of obstruction and the Democrats the party of totalitarianism.
IV. The President acknowledged the risks of terrorism and the need to repair our relationships with our neighbors. One year later - we are getting more enmeshed in a war in Afghanistan and have not been able to resolve the Iraqi problems or the nuclear proliferation of the Iranians.
V. He would preserve his popularity on the basis of meeting the needs of the nation or he declared he would be a one term President. One year later- he is still popular however independents are defecting from his leadership in droves and even a Democratic party stalwart like Massachusetts has elected a Republican senator.
In summary this first year of the Obama presidency has resembled the impotence and arrogance of the Carter Presidency. As Hilary Clinton declared during the campaign for the Democratic Party nomination, the greatest detraction of an Obama Presidency might be his inexperience in public office. Year two will be a telling year as his majority in the Congress and the Senate will diminish substantially after the November elections.

skin of color 2010

Thursday, January 21st, 2010

Skin of color is a term in dermatology referring to people other than Caucasian . It came about because of recognition of some of the unique characteristics of darker skinned people with regard to treating skin disease or signs of aging. For instance, a laser may cause lightening or darkening of skin color in a darker skinned patient and yet be perfectly safe for a white skinned Caucasian.

Somewhat conversely, Elliott Battle Jr, MD, noted dermatologist and African American, was speaking over the weekend and said that in the future there will be no reference to skin of color but rather to skin of ethnic origin. He pointed out that by 2050, 65% of the American population will have skin of some color and differences in skin will refer to genetic differences of ethnic origin and not how brown or yellow our skin color might be.

Flashback: I am at the University of Illinois in 1963 and I am working with the Southern Christian Leadership Conference under the leadership of Martin Luther King Jr, preparing for the march on Selma Alabama. Like my father before me I believe fervently in the equality of all men and I want to do my part in the struggle for parity among people. I am in a church training for the march and we are simulating being beaten by trainers to prepare us for what lay ahead. The male marchers lay across the females to protect their bodies at the same time covering our heads while we expose our kidneys to whatever violence may follow. The trainers call a halt to the exercise and as we rise we note a 5 year old little girl lying on the floor in the middle of the room having assumed a fetal position as she imitates our protective posture. Tears well up and it is hard to continue. Many of us, myself included, cannot handle the stress. I cannot march. I raise funds instead.

Then as now I am not color blind. I have no control of my awareness of color or ethnicity despite the enrichment each unique culture brings. Yet I am ashamed that I am not color blind. Frederick Douglas said Abraham Lincoln was the only man he ever met that was truly color blind. I am pleased that Dr Battle sees the future pragmatically and optimistically. We are not a nation of color because we are all shades of color, shades of light, shades of dark. We are genetic variations of ethnic origin and the uniqueness of our breeding: Irish, Mexican, Brazilian, African, Anglo-Saxon, Ashkenazi Jew, characterizes our diversity. “I have seen the enemy, and it is us” said Pogo. The future has arrived.

Tax on Tanning Parlors Is a Sin Tax

Monday, January 11th, 2010

I am not sure how many of the public noticed a provision in the proposed health reform legislation that would have placed a federal tax on cosmetic procedures. The provision was known as the Bo-TAX and it aroused a unified response from the medical community in general and organized medicine in particular. This proposed tax was a clear example of how out of touch the Congress is with the needs of the public. This always happens in government when those who govern make a career of governing rather than serving the electorate. The proposal would have directly impact women aged 30-60 who are trying to compete in the job market against younger women and against men. Regardless of its validity, women must compete in part on the basis of appearance whereas men can compete on the perception of power (often depicted by money). At a time when unemployment is so high and the economy is struggling to regain a semblance of security, this tax places a direct burden on a particular segment of the public who utilize cosmetic services.
In place of that proposal a new tax on tanning salons has been included in the bill. Not unexpectedly it initiated a whining response from the tanning industry that the tax is not only discriminatory but is a substitute cosmetic tax. Nonsense!!! The tanning industry has been getting away with murder, literally, for decades. The World Health Organization has now directly linked tanning parlors as a direct cause of malignant melanoma and other skin cancers. Malignant melanoma is now the 7th leading cancer killer in the United States, kills some 8000 people yearly and claims 80,000 victims each year. Skin cancer is the most frequently occurring cancer in the world and now causes 1,000,000 new cases yearly in the United States.
This is not a cosmetic tax. It is a sin tax- similar to taxes on alcohol and cigarettes. If individuals wish to engage in risky behavior which directly causes cancer and other severe illnesses they need to pay for their avarice. When people selfishly create harm and increase the health care burden which directly translates into higher insurance premiums and higher cost of providing health care it is incumbent upon them to pay some of the costs they directly produce. So often it is the perpetrators, the tavern owners, the smoke polluters, the self-indulged, who cry for sympathy when responsible adults institute limits on behavior and who insist that individuals accept responsibility for their actions. Finally the Congress passes an intelligent bill and the media reports criticism and derision from the perpetrators instead of congratulating legislators who have a dismal record of responsible health care legislation in the first year of the Obama administration.

Managing Cancer

Sunday, January 3rd, 2010

On or about August 27, 2002 I awoke in the morning and went to work as usual. I did not know that my world as I knew it was about to change irrevocably. On a subliminal basis I knew that I had cancer of the soul. My marriage was in name only, my family dissipated, my work was my passion. I did not understand that in a few hours, a Kafkaesque moment, I would turn yellow and the cancer in my soul would become the cancer in my pancreas. That was then and now I am a 7 year survivor of a cancer few get to tell about.
Back then, after a rapid work-up, I was presented a chance to become a patient in a phase III clinical trial. I enlisted before I knew what the trial entailed. Dr. Talamonti asked how I could volunteer with so little knowledge. “Look,” I said. “I have a minimal chance of survival regardless and the possibility of remission if I participate. At the least, someone else may benefit from my experience.” I was unaware of statistics which indicated that from 1980-1989 patients in clinical trials had up to a 400% greater chance of remission than patients who did not participate. So who wouldn’t participate?
75% of adults. That’s who. 75% of adults across all spectra of cancer do not participate in clinical trials. Yet the numbers get worse. My friend, Dr. Jane Petrow, showed me that today less than 5% of women with breast cancer participate in clinical trials. There must be an explanation. Antipathy? For God’s sake you are dying! Who the hell has antipathy at that point? Maybe false bravado, but certainly not antipathy. I judge there are 2 explanations.
Patients: Even today adults with cancer believe that clinical trials involve risk to them. They think they may receive a placebo. There are no placebos in a level III clinical trial. Flashback. The year is 1978 and I am asked to see a woman with Hodgkin’s lymphoma who has a skin rash. I enter her room to find that the lady is in a coma and she has disseminated varicella, chicken pox if not herpes zoster. Herpes Zoster. I erupted with anger. This was about me not the patient. Why had I been called in at all? I was helpless before this woman who had disseminated cancer, disseminated varicella, was clearly dying, and would soon leave 3 children and a husband at age 35. In anger I can be irrational so I began calling colleagues who might know of a clinical trial for this woman. I found one at the University of Chicago. Through a series of not so ethical subterfuges I got her transferred to the U of C Hospitals where she recovered and went on to remission from lymphoma. I later spoke with her attending doctor at the U of C Hospital and he told me the miracle of her cure was not in the drugs used in the trial but in the supportive care she received which was not available at most community hospitals. That’s the rub, the misconception. Patients in level III clinical trials receive the latest therapies, the best of old therapies, and very importantly a level of care that is often not available in a community setting.
Doctors: Doctors today are between a rock and a hard place. Their incomes depend on caring for sick people. Their egos are not satiated by referring every sick patient to a university type setting. They are not always privy to the inside advantages of medical institutions and pharmacopeia. And if the therapy they advise worked for Mrs. Jones why not for you.
But that’s not the point. The point is that cancer today gets far less government appropriations for research than bills filled with pork to advance the careers of politicians who are supposed to be serving us. The point is the system is not geared to give the majority of patients the optimal care that may be available. The point is that adult patients are fearful of the unknown and a known treatment that does not work may feel preferable to one that is being studied. The bottom line for me is that I survived, who knows how or why, and that it is painful to see cancer patients limit their chance of success for any of the above reasons.
So today I am free of the cancer in my pancreas, free of the cancer in my soul, and I am forever grateful for the wonderful care I received at Northwestern University Hospital and the opportunities they presented for me.