The Truth About Message Boards and Plastic Surgery

A few weeks ago, a friend of mine called me and asked me if I could refer him to a rhinoplasty surgeon in New York. His brother lives in New York and his brother wanted to have his surgery done in New York, as opposed to flying out to LA. I told him that I would ask a colleague of mine who he would recommend, since my colleague, also a board-certified plastic surgeon, had done his residency at NYU and continues to maintain close ties with colleagues in New York. I gave my friend the names of two surgeons in New York and, within minutes, I received a frantic call from my friend, “I looked up the two surgeons and the first one was rated only two stars! I can’t believe your colleague would give me the name of a surgeon with only two stars! There is no way I am sending my brother to him!” I just shook my head. A referral from a respected, board-certified surgeon is absolutely as good as it gets – to rely on a message board over a surgeon’s referral struck me as absolutely insane. But it got me thinking about the power that some of these plastic surgery web sites wield.

One thing that is probably fairly obvious to many people is that the doctors who pay more get the best placement on most sites. So, if a patient is in a hurry and just glances at a site and jots down the names of the first few doctors that are placed most prominently on the site, that patient is limiting herself to just those doctors that have simply paid for the best placement. In many cases, these are the doctors that need the business – they made a business decision that it was worth it to spend thousands of dollars to be placed prominently on the site because it will generate business and justify the cost.

Something that many people may not know is how the message boards and rating systems work. Presumably, most people go to the message boards to see what other patients have to say about a certain doctor. However, are those comments praising the doctor really from satisfied patients? Maybe not. I recently met the CEO of a web marketing company who described a type of marketing that his company does in which he and his team get paid by doctors to regularly log onto all the plastic surgery message boards and rave about those doctors. The CEO’s employees pose as patients and rave about what a wonderful surgeon so-and-so is and how they wouldn’t go anywhere else and how the doctor changed their lives, etc. The more the doctor pays, the more time the team will spend posting glowing reviews about the doctor. The CEO said, “If you visit some of these web sites, you will see names of doctors you never heard of with rave reviews and ten stars out of ten. You will also notice that some of the top doctors have fewer rave reviews, fewer stars and often more negative comments.”

I had always just assumed that many surgeons out there routinely had their nurses and secretaries post glowing reviews of them; in fact, I’m sure many surgeons personally post glowing reviews of themselves! However, I hadn’t realized that companies actually get paid to do that. Just after I heard about these tactics, a company called the “LifeStyle Lift” was fined for just that – employees were posing as patients raving about the merits of the LifeStyle Lift.

As with most things in life, caveat emptor applies to plastic surgery message boards and web sites as well.

The “Taco Bell” Facelift

Whenever I see a surgical procedure that is patented, I cringe, expecting a marketing ploy devised by a slick doctor and an even slicker publicist. A case in point is a type of facelift that is getting a lot of press lately. The procedure shall remain nameless, but those of you who follow trends in plastic surgery know what I’m talking about – you’ve heard the television infomercials and advertisements (bad sign), seen the cute logo and the catchy name (another bad sign) and heard about the incredibly low fees (a really bad sign).

The way this procedure is presented to the general public has so many things wrong with it I don’t know where to start. First of all, it is difficult to determine from the information available to the public what the procedure is – is the “facial firming” that’s promised a surgical or non-surgical procedure? Who knows?

The “facial firming” procedure is described as a breakthrough that is so unique that it warrants its own patent. In truth, the procedure was described by a Belgian surgeon in the 1990’s. The American surgeon who “patented” it simply took the Belgian surgeon’s procedure, changed the name, hired a publicist and away he went.

It turns out that the procedure is actually a mini-facelift performed under local anesthesia, not unlike the first facelift performed over 100 years ago. The only difference between that early facelift performed in Berlin in 1901 and the new, patented lift is use of two permanent purse string sutures – of course, this technique was also borrowed from the Belgian surgeon.

Another aspect of this that is obvious to surgeons, but perhaps not to the general public, is that surgical procedures cannot be franchised, like a Taco Bell. Surgical skills are honed over years; one cannot just walk into a clinic and walk up to the counter and say, “I’d like a facelift and I’ll take whichever surgeon that’s not busy today”.

The following is an interesting article that applies to this subject:

Facelift firm placed bogus online reviews

By JENNIFER PELTZ (AP) – 2 days ago

NEW YORK (AP) — The online journal gave a chatty account of a problem-free face lift. "You will never regret it," the patient wrote.

But the seemingly satisfied customer actually was an employee of the firm behind the Lifestyle Lift, writing as part of a company campaign to plant plugs for the procedure online, state Attorney General Andrew Cuomo said in announcing a $300,000 settlement with the company Tuesday.

His office said the settlement appeared to be one of the first to address so-called astroturf marketing, or creating a bogus grassroots buzz about a product.

Troy, Mich.-based Lifestyle Lift Inc. said its informational material now accurately reflects actual patients' comments and is clearly labeled as coming from the company.
"We want to be acknowledged as a model of integrity and accuracy," company President Gordon Quick said in a statement.

Widely advertised through television infomercials as a relatively quick and inexpensive form of face lift, the Lifestyle Lift has been performed on more than 100,000 people since 2001, according to the company. It's affiliated with a network of doctors in New York and 21 other states.

The company has aggressively guarded its online reputation. In 2007, it sued an Arizona man who maintained a consumer-oriented Web site that included criticisms of Lifestyle Lift, saying the site's use of the procedure's name infringed on the company's trademark and amounted to false advertising. A federal judge in Michigan dismissed the case last year, saying the site was commentary protected by the First Amendment.

But Lifestyle Lift also came up with another new way to fight back: Having staffers post glowing reviews, comments and testimonials that appeared to come from clients.
"I need you to devote the day to doing more postings on the Web as a satisfied client," employees were told in one internal e-mail, according to the attorney general's office. Another internal message directed a worker to "put your wig and skirt on and tell them about the great experience you had."

The disguised workers did that and more, sometimes pushing to get message boards to remove critical posts and even setting up pro-Lifestyle Lift Web sites that masqueraded as independent views, Cuomo's office said. The postings dated back to early 2007, the attorney general's office said.

One such site featured a detailed "journal," stretching from a first consultation to two months after the procedure, and included photos and an exhortation to "GO FOR IT." Another supposed first-person account came complete with the names of the writer's children.

"This company's attempt to generate business by duping consumers was cynical, manipulative and illegal," Cuomo said in a release. He said the tactics violated consumer protection laws.
Lifestyle Lift said Tuesday the disputed endorsements were "representative of" real patients' comments but acknowledged they weren't rendered verbatim or labeled as coming from the company.

The company, which said it has since changed management, will pay the state $300,000 in penalties and costs. The settlement came as the attorney general's office investigated the company's practices, without any litigation in court.

The Federal Trade Commission is working on revising its nearly 30-year-old guidelines on the use of testimonials and endorsements to reflect the growth of online marketing. The review comes amid heightened attention to the role blogs and Internet comments can now play in a product's fortunes.

In the meantime, the American Advertising Federation, an industry group, has its own guidelines specifying that testimonials "shall be limited to those of competent witnesses who are reflecting a real and honest opinion or experience."

"We think the consumer has the right to know that an advertisement is an advertisement," spokesman Clark Rector said.

The Truth about Before and After Photos

I am always amazed at how much credence people put in before and after photos. These days, it’s rare that a patient will ask me to see before and after photos; since I’ve been in practice 15 years, they don’t need to see photos before scheduling surgery. When a doctor is starting out in practice, however, before and after photos are almost essential to make a prospective patient feel confident in the doctor’s skills. The only problem: many doctors know how much weight patients place on these photos, so it is too tempting not to do some very misleading things.

The first example I saw of misuse of before and after photos was about 13 or 14 years ago when a young dentist starting out in Beverly Hills invited me to lunch at the Peninsula Hotel. He brought with him a beautifully bound book of before and after photos with his name embosses in gold on the cover. The photos showed impressive results of veneers and dental implants and other cosmetic dental procedures. The only problem: I had seen the exact same book with the exact same photos at my dentist’s office in Brentwood the week before. My dentist used the book to show examples of what modern dentistry could do, but he did not claim that the patients in the book were his. At the Peninsula Hotel, I just sat and nodded and commented on the beautiful work. Obviously, I had no interest in working with such a dishonest person.

Around the same time, a patient from Orange County came to see me about laser resurfacing. The CO2 laser was new at that time and few people had much experience with it. The patient told me that she had just seen a “laser expert” in Orange County who had such extensive experience with the CO2 already that the doctor already had lots of impressive before and after photos. I told the patient that I didn’t have before and after photos yet, since we had just started doing the CO2 laser a few months before. I told her that I could show her some stock photos that were provided by the manufacturer, Coherent Laser – at least she could see some stock photos demonstrating what the laser was capable of doing. I handed her the book and, after a few pages, she stopped and looked up at me and said, “Oh my God. These are the exact same photos that the other doctor said was her work!”

Over the years, I have seen many examples of misleading before and after photos. One patient brought in her before and after photos that her previous surgeon had taken at another office. The lighting in the before photos was poor, there was extensive shadowing and the background was a yellowish-green bilious color. The after photo on the other hand, was overexposed, and the background was a brilliant royal blue. After I pointed this out to the patient, she recalls that she found it curious at the time that the doctor had two completely different rooms for the before and after photos.

Of course, the ultimate tool in 2009 is Photoshop. I can usually spot the results of Photoshopping in before and after photos, but not always. Occasionally, a patient will bring in before and after photos from a newspaper ad or from a web site that shows an obese patient in the before photo and a toned and fit patient with a six-pack in the after photo. They say, “I want that, Dr. Ryan” as they point to the six-pack. I explain that I have done hundreds of liposuction cases over 20 years and that it’s simply impossible to achieve such results with liposuction.

Bottom line: I would be skeptical if I saw dozens and dozens of spectacular before and after photos on a web site or in a surgeon’s before and after book. Of course, there are many surgeons with lots of photos of their work and they show good quality and unretouched photos as an educational tool, not as a sales tool. However, it is getting more and more difficult to distinguish between the two.

Dr Ryan’s Personal Skin Care Regimen

Almost every day, a patient asks me, “What do you do for your skin, Dr Ryan?” The truth is that for years, I did absolutely nothing for my skin. In fact, until I was around 37 or 38, I purposely tanned my face. I remember skiing at Aspen and trying to get as much sun as possible on my face; I would sit on the deck at Bonnie’s having lunch and rotate my body to follow the sun so my face got maximum exposure! My face was almost purplish, it was so sun-damaged.

As someone of Irish heritage, I am what’s classified as a Fitzpatrick skin type II, meaning that I have fair skin and blue eyes and that I burn easily in the sun. My skin issues pertain mainly to dilated (or “broken”) blood vessels and ruddiness. Therefore, I need a skin care regimen that is very gentle so that more blood vessels do not “break,” which would lead to even more ruddiness. On the other hand, many people with olive skin and brown eyes (Fitzpatrick skin types III and above) have issues with hyperpigmentation (i.e., brown spots or patches), not ruddiness and broken blood vessels. Therefore, these patients often need to focus on beaching creams such as hydroquinone or kojic acid. People with significant sun damage, fine lines and brown spots may need to focus more on products that contain ingredients that help to reverse sun damage; these ingredients include kinetin, retinol or acids. In people with sensitive skin, however, some of these ingredients may be irritating.

In the last five years, I have made great strides with my skin and here’s how I did it.

1. Gentle cleanser and moisturizer – Because of my sensitive skin, I require a very mild cleanser and moisturizer. However, I could never find one that met my exact specifications. So I decided to develop my own. Every morning and night, I use the Dr Frank Ryan cleanser and moisturizer. For people who prefer their skin care products to be paraben and sulfate-free, I also have a paraben and sulfate-free cleanser. The products are aloe-based, and contain ingredients like sage and arnica.
   


2. Broad-spectrum, high SPF sunblock – This is the most important thing for good skin. About five years ago, I began using a daily moisturizer with an SPF of 15. After a year or two of doing that, it occurred to me that I should probably use something stronger. So I tried many different sunscreens and concluded that the Skinceuticals SPF 45 was the best, in my opinion. It does not leave the skin white and provides excellent broad-spectrum coverage, since its main ingredient is zinc oxide, still the best sunblock out there in my book. This alone began to improve my skin dramatically. Other excellent sunblocks are made by Epicuren and Fenix. I am currently formulating my own sunblock for the Dr Frank Ryan line.
   


3. Skin Refining Gel – My secret weapon is the Dr Frank Ryan Skin Refining Gel. This product is very difficult to categorize, but in general, it serves to minimize or even eliminate the appearance of pores, fine lines and irregularities in skin texture or tone. It contains several topical vitamins, arnica and alpha-lipoic acid and is lightly tinted. Remarkably, many men are absolutely hooked on this product, because it improves their skin significantly, but is not considered “make-up”. When people comment on my skin, I always confess that I had a little help from my Skin Refining Gel.
   

There are many, many excellent products on the market that I don’t use only because they are not what my skin needs. Product lines like Kinerase and Epicuren are excellent and we carry both lines in my office. Individual products like Renova and Tri-Luma and Cellex-C are all excellent.

Bottom line: each person needs a skin care regimen specifically designed for his or her own skin type. A product like Renova, which would be beneficial for many people, would simply be too strong and irritating for my sensitive skin. On the other hand, a simple, gentle skin care regimen like I use would simply not be strong enough to help someone with severely sun-damaged, weather beaten skin.

Next up: the laser and light therapy devices that I have used – and to continue to use – to improve and maintain my skin.

The Mini-Facelift under Local Anesthesia

For most of my fifteen years in practice, I performed the vast majority of my facelifts under general anesthesia with the patient asleep. About three or four years ago, a very determined young lady practically begged me to do her mini-facelift under local anesthesia, meaning that she would be awake. Because she had a high pain threshold and was stoic by nature, I agreed to do so. The procedure was a breeze and she raved about how easy the process was and how quickly she recovered. After that, I began to do more and more mini-facelifts -- and even more extensive facelifts -- under local anesthesia. I realized that in some cases, I could accomplish the majority of what I needed to accomplish without general anesthesia – the key was to choose the patients carefully and to educate the patient beforehand about what to expect.

When performing a facelift under general anesthesia, we routinely require the patient to obtain preoperative blood work and other tests, including an EKG and a chest X-ray. General anesthesia requires that an anesthesiologist be present, which adds to the expense. Furthermore, there is typically a bit more recovery involved after general anesthesia. Mini-facelifts under local anesthesia, however, usually don’t require the preoperative lab work and an anesthesiologist is not required to be present.

Local anesthesia typically also involves giving an oral medication like Valium; this type of anesthesia is known as “local with oral sedation”. The patient is given Valium approximately 20 minutes before beginning the procedure; that way, the patient is drowsy when he or she is taken into the operating room. Once in the operating room, local anesthesia (lidocaine) is injected into the face, not unlike at the dentist’s office. This is, perhaps, the most uncomfortable part of the entire procedure, more so than the surgery itself. The Valium, however, really takes the edge off this part and most patients say afterward, “The injections really didn’t hurt much at all!” After the local anesthetic has taken effect, the patient typically feels little or no discomfort for the rest of the surgery.

The mini-facelift takes a little over an hour and the patient is walking and talking immediately after the procedure. We typically wrap the face and neck in a light bandage that is removed the next morning when we see the patient in the office. After surgery, we send many of our patients to an after-care facility where they are watched by nurses. However, in some cases, the patient is able to go home if there is a family member or friend who can keep an eye on the patient overnight. Where the patient spends the first night after surgery depends on many variables, including the complexity and length of the surgery and the health and age of the patient. The stitches, located around the ear, are removed in seven to ten days; bruising and swelling is usually minimal. In fact, I am always amazed how quickly patients recover from these procedures. Most are back at work in a week.

In younger patients (30’s and 40’s), the mini-facelift may all they need. In patients in their 50’s and older, other procedures such as a browlift and upper and lower eyelid surgery may also be indicated. As the list of procedures increases, I lean more and more toward general anesthesia.

In older patients, a mini-facelift may still be appropriate. However, these patients need to be educated that a mini-facelift has limits in what it can do. If the neck is extremely saggy, for example, a mini-facelift is probably not the best procedure. Simply put, the mini-facelift can’t accomplish as much compared to what can be accomplished with a more extensive facelift.

In conclusion, the mini-facelift under local anesthesia is a quick and simple procedure that I am incorporating more and more in my practice. The results are excellent and the patients are happy – and that makes me happy.

LATISSE -- The Key to Fuller Eyelashes

Allergan Corporation (the makers of BOTOX and Juvederm) recently released their prescription eyelash booster, LATISSE. When people ask me if it really works, my response is an emphatic YES!

LATISSE is an FDA-approved, once-daily treatment applied to the base of the upper lashes with a sterile, single-use-per-eye dosposable applicator. Most users see significant results in two to four months. If use of LATISSE is discontinued, the lashes simply return to how they were before the treatments were begun.

Latisse has an interesting history. The main ingredeint is based on a glaucoma drug, bimatoprost, and its effects on eyelash growth were discovered by accident.. Several years ago, people who were using LUMIGAN (the glaucoma drug containing bimatoprost) noted spontaneous eyelash growth. Based on those findings, Allergan began investigating the use of this drug for eyelash growth. This history is not dissimilar to that of BOTOX, which was initially used for muscle spasms. When people noticed that it also made wrinkles disappear, it was eventually approved for the elimination of wrinkles as well.

Since LATISSE is from a respected pharmaceutical company such as Allergan, it makes sense that there is solid scientific data to support its safety and effectiveness. In terms of effectiveness, studies have shown that there is, on average, a 25% increase in eyelash length, a 106% increase in eyelash thickness and an 18% increase in eyelash darkness. In terms of side effects, there was a 3.6% incidence of eye redness, a 3.6 %incidence of eye itchiness and a 2.9% incidence of skin hyperpigmentation. Less common side effects included eye irritation, dry eyes and redness of the eyelids. Hyperpigmentation refers to a slight darkening of the eyelid skin, which may or may not be reversible. There is also a possibility of increased brown pigmentation to the iris, the colored part of the eye.

In my experience with Latisse, I have seen only a handful of patients complain of mild irritation or redness or itchiness, but these symptoms were mild enough that none of these patients discontinued the product. In general, the feedback has been overwhelmingly positive.

Many people are familiar with competing over-the-counter products that promise to make the lashes fuller. Many of these competing products worked quite well -- and that's because they were knocking off Allergan's ingredient! However, because bimatoprost is patented and, more importantly, because it is a drug, these companies were skirting the law. They would try to get around these problems by very slightly changing one or two molecules on the drug, but it was only a matter of time until Allergan came on the scene with the real deal.

At this point, why would anyone use anything but the patented, prescription-only LATISSE from Allergan?

Although any physician can prescribe LATISSE, it can be obtained directly from many plastic surgeons and dermatologists, who dispense LATISSE in their offices. The suggested retail price is $120 and one container lasts for up to two months.

More detailed information can be found at www.LATISSE.com.

Footnote: Last Thursday Allergan officially launched LATISSE with an event on La Cienega Boulevard in LA. The room was filled with beauty editors from all the top magazines as well as celebrities like Jewel, Debra Messing, Debbie Mazur, Mandy Moore, Debbie Matenopolous and others. The thing I found interesting was that almost one half of the people I met that night who requested LATISSE prescriptions from me were men -- I have a feeling that the male market for LATISSE will be significant.

Non-Invasive Fat Removal

Erchonia Medical has developed what is considered the Holy Grail of plastic surgery: a non-invasive, painless treatment that melts fat. The Zerona is a low level laser that emulsifies (i.e. liquefies) fat, allowing the body to excrete it naturally. Treatments are performed in thirty minute sessions, every other day for two weeks and are completely painless. After each treatment, we encourage our patients to increase their water intake, which helps to eliminate the emulsified fat. Our aesthetician performs lymphatic massages after each treatment which is also helpful in eliminating the fat. Some patients choose to wear a compression garment after the treatment, similar to what is worn after conventional liposuction.

So far, my office staff has seen some very exciting preliminary results. We have used the Zerona to treat the arms, abdomen, love handles, thighs and knees. We have also treated the jowls and under the chin. One staff member lost ½ inch off her arms and others have lost over an inch off their hips and thighs.

Just a week ago, I had an experience in surgery that convinced me that the Zerona has huge potential. I was performing liposuction on a male patient’s abdomen and love handles. During the procedure, I noticed immediately that the fat that was being removed was coming out very smoothly and was virtually bloodless. It appeared almost melted. Then it occurred to me that this particular patient was the first liposuction patient in my practice to have undergone a preoperative Zerona treatment. It appeared that the Zerona had indeed emulsified and liquefied the fat and that we were suctioning out what the Zerona had liquefied 72 hours earlier!

Currently, we are performing the Zerona on several subjects and accumulating more data.

Check back in a few weeks for an update.

Breast Implant Update

Most people are aware of the difference between saline and silicone breast implants. Most people are also aware of the difference between round and teardrop breast implants. But what about the difference between moderate profile, moderate plus and high profile breast implants? These are terms that Mentor Corporation uses to describe their three different implant profiles. Moderate Profile refers to a less projecting, yet wider implant; High Profile refers to a more projecting, yet narrower, implant. Moderate Plus is somewhere in between these two, with a moderate amount of projection and a moderate width. Projection refers to the degree to which the implants protrude from the chest. The type of implant chosen is largely determined by each patient’s anatomy. The following two examples illustrate how these different implants can be used.

Case #1

Recently, a patient who had undergone breast augmentation came to me complaining that her breasts appeared too wide for her frame. She complained that the implants stuck out under her arms and that her breasts were too close together in the cleavage area. After examining the patient, it was immediately apparent that she was exactly right: her implants were simply too wide for her rib cage. In fact, the patient was very close to having synmastia, where the breast implants touch in the middle, often eliminating the cleavage completely. I explained to her that the combined diameter of the two implants was simply wider than the width of her chest. The solution: narrower implants. Not necessarily smaller (i.e., less volume), but narrower. Since she stated that she wanted to maintain a fair amount of projection, the perfect solution would be the narrower – yet more projecting – high profile implants. So I removed the moderate implants and replaced them with high profile implants, which fit her chest diameter better and maintained the projection.

Case #2

A few months ago, I saw a patient complaining of what she described as a “strange” shape to her breasts following breast augmentation. She couldn’t put her finger on what exactly made the breasts seem strange to her -- she just knew she didn’t like them. Exam revealed very narrow breasts that projected excessively from her chest. She had a very wide rib cage and a very protruding rib cage and it appeared to me, after examining her, that she had high profile implants in place. The combination of narrow, high profile implants in a patient with a wide, prominent rib cage resulted in a strange look indeed: very wide cleavage and breasts that looked like two oranges abruptly jutting off the chest. I explained that we needed to remove the high profile implants and replace them with moderate implants. The extra width and reduced projection would fit this patient’s anatomy perfectly. Sure enough, a simple switch to slightly larger moderate profile implants solved the problem.

The above examples represent cases where simply changing the profile of the implant solved the problem. There are many cases where more needs to be done to solve the problem, such as repairing synmastia or making the pocket smaller to accommodate a smaller implant diameter.
In conclusion, the three different implant profiles available today allow plastic surgeons to take into account variations in breast and chest wall anatomy to produce predictable and satisfactory breast augmentation results.