Cosmetic Botox Blog

Sharmeen Obaid-Chinoy was born in Karachi Pakistan, emigrated to Toronto, Canada and this passed weekend won an academy award here in Los Angeles for her short documentary film Saving Face. The film documents the plight of Pakistani women who are disfigured by having acid poured on them usually by relatives, husbands or rejected suitors. The acid damages the skin, sometimes exposes the underlying bones and often times causes blindness in one or both eyes. The film chronicles the efforts of a Pakistani born British plastic surgeon, Mohammad Jawad,  to reconstruct their faces and restore their dignity. It is the first win for a Pakistani film. A win that instills pride and shame at the same time. Over 100 such attacks occur in Pakistan each year. Most go unreported and the women live secluded lives due to the circumstances surrounding these attacks (in the case of husband attackers they do so out of fear for their children) so the number of victims could even be double that. In the course of the film a girl describes being burned at age 13 for rejecting the advances of her teacher. In the Western world that teacher would have been prosecuted. Although it is rare a female Pakistani lawyer took up the legal case of one of the victims in the film and successfully managed to have the perpetrator convicted. Sadly these women require multiple operations to regain some resemblance of normal appearance. There is a report of a New Delhi India girl who underwent 25 reconstructive operations to treat disfiguring from acid burns.


The woman in the trailer with the severely disfigured face had acid thrown on her face by her husband after she had filed for divorce. It was almost as if half her face was wiped out. What was left was one eye, half a nose and a mouth that couldn't smile. The prosthetic face mask she was fitted with was voluntarily made by Dubai-based Indian anaplastologist Daril B. Atkins

The film will debut on HBO television March 8, 2012.

A few random such attacks have occurred in the West such as the 2008 attack of a London England model and TV presenter Kate Piper who sustained an acid burn of the face inflicted by an ex-boyfriend and his accomplice. Those 2 men are now serving life sentences in a British prison. Pakistan's Lower House of Parliament unanimously ratified the Acid Control and Acid Crime Prevention Bill On May 10, 2011. The bill calls for life imprisonment of assailants but to date prosecutions have been minimal.

Pakistan's prime minister, Yusuf Raza Gilani, said Pakistan would confer on Obaid-Chinoy "the highest civilian award upon her return".

"Pakistan is reportedly the third-most dangerous country in the world for women after Afghanistan and Congo...". It was only a few years ago that there was a Time magazine cover photo of a young Afghan woman whose nose was cut off in retribution for a similar attack.

Pain control during surgery has been quite good for a number of decades. Refinements in recovery from anesthesia to lower the incidence of nausea, shaking etc. after surgery have been accomplished by adjusting the mix of anesthetics used and employing newer medications like propofol, toradol, zofran etc. More recently the focus has been on controlling pain after surgery to lessen the need for narcotics, shorten recovery times after surgery and improve surgical results in general. The opioid narcotic medications commonly used can become addictive, have small windows between effective and overdosing quantities that affect breathing and tend to be constipating.
Local anesthetics have been in regular use since the late 1800s. Most people currently get their exposure to them at the dentist office where novocaine also called lidocaine is injected prior to dental work. The onset and duration of action varies between different local anesthetics. Novocaine is one of the quickest onset and shortest acting local anesthetics. About 10 years ago surgeons began using longer acting bupivacaine applied via external pumps and tubes like the on-Q system to the operative site as a means of pain control after surgery.
The thought was that slow constant administration of a long acting local anesthetic to the operative site would allow for a quicker recovery after surgery, allow the patient to get up and around earlier and decrease the need for narcotic pain killers after surgery. Their use became especially popular with orthopedic surgeons who would place the catheters directly over bones or into joint spaces after surgery (such as knee or shoulder surgery) and to a lesser extent with general and thoracic surgeons. In 2007 it was discovered that prolonged exposure of joints to local anesthetic caused permanent loss of cartilage in the shoulder joint and multiple lawsuits have been filed since. Currently, there is no effective treatment for cartilage loss; patients who have experienced it have required additional diagnostic and therapeutic procedures and some required arthroplasty or shoulder replacement. Use among plastic surgeons was more limited and confined mostly to tummy tuck and breast surgery patients to decrease reliance on pain medications and allow for earlier ambulation after surgery. I tried this in the past on tummy tuck patients and was unimpressed by its ability to do either so I stopped doing it.

In October, 2011 the FDA approved Exparel which has just recently become available for public use. Exparel is long acting bupivacaine that has been placed in a container of microscopic fat cells. The anesthetic is then slowly released from the fat cell container into the body after injection. This extends the effectiveness of the anesthetic from a few hours up to 3 days. EXPAREL is the first and only multivesicular liposome-based local anesthetic that can be used around surgery in the same fashion as current local anesthetics. The medication is injected near the end of surgery and should not be injected with other local anesthetics at the same time as that could result in sudden release of all of the anesthetic from the fat cell containers. In clinical studies exparel was most effective in the first 24 hours after surgery. The fat cell containers can be damaged by contact with the liquid antiseptics commonly used just prior to surgery.

Due to the large surface areas involved in body contouring surgery like breast surgery and abdominoplasty I suspect this medication will prove most useful for rhinoplasty, facial implant, ear and hand surgery. Clinical studies have shown this medication to be most effective in the first 24 hours after surgery and to significantly reduce the need for narcotic pain medications after surgery.

I think we will see many more fat cell packaged medications in the future.

Obstruction to airflow in the lungs can be due to
fixed or irreversible lung disease (COPD)reversible (responsive to medications) obstruction due to heart failurereversible (responsive to medications) obstruction due to asthmaThe obstruction can be due to just one of the factors or any combination of 2 or more factors.

In asthma the walls of the breathing tubes into the lungs swell (become inflamed), muscles surrounding the tubes contract squeezing the tubes and then increased mucus secretions inside those tubes plugs them. This results in obstruction to airflow with audible wheezing and a tight feeling in the chest as the individual tries to get the air through narrowed plugged tubes. Attacks can be mild resolving quickly with medication or severe and life threatening.

Attacks of asthma can be stimulated or triggered by environmental factors like pollen, cigarette smoke, dust mites, pet hair, insect excretions, air pollution, stress, exercise, infections etc. The trigger can be something you are allergic to. The primary medications used to treat asthma are bronchodilators which counteract the muscle spasm and steroids which treat the inflammation.

For the asthmatic undergoing cosmetic surgery an attack can be triggered by irritation from the breathing tube in general anesthesia, dehydration associated with any surgery, inability to clear secretions while lying down under the influence of anesthesia or even pain medications used during surgery. The anesthesia staff needs to adjust the medications given in such situations and the patient needs to bring their inhaler with them to surgery, if they have one. If they patient smokes it is imperative that they not do so for at least one week prior to surgery. Cosmetic surgery in an asthmatic who was smoking within days of surgery is a dangerous combination as they are very sensitive to asthmatic triggers.

Abdominoplasty and belt lipectomy patients who are asthmatics are at higher risk of attacks because the immobility after surgery combined with greater pain medication needs.

The steroids used to treat inflammation in asthmatics also prolong the healing process so sutures may have to stay in longer than they otherwise would. The adverse affect on healing can be reversed by taking Vitamin A before and after surgery. The vitamin does not affect the anti-inflammatory effect so it will not exacerbate the asthma.

This is a tricky situation because even if normal lung function tests and a normal physical examination an asthmatic attack can occur due to any of the factors mentioned above. Furthermore, significant impairment of lung function can occur in asthmatics without symptoms. The history and general physical examination may not accurately indicate the severity of the asthma. The answer is not to just do the surgery under local because you think it would be safer. If you have an asthmatic attack induced by a cosmetic procedure and cannot have a breathing tube placed because of the spasm you will not survive. The answer is to do the surgery in an environment where should any of these problems arise the right personnel and equipment are present to handle the situation. Certified operating rooms will have the necessary oxygen, IV fluids, inhaled and injectable bronchodilators, oral and intravenous anti-inflammatory agents to treat an attack. It is highly unlikely that a non-certified operating room will have those medications.

Only asthmatics with stage I disease and an forced expiratory volume greater than 75% of predicted values can undergo surgery without a higher than normal risk of airway complications. Any asthmatic who has taken steroids, whether orally as a pill or as an inhaled medication, within 6 months of surgery needs perioperative steroids to cover for diminished adrenal function. Inhaled steroid medications may have to be temporarily replaced by oral prednisone until the patient has recovered from surgery. Any asthmatic with audible wheezing should not be having elective non-emergent surgery.

I am personally aware of a fit individual in his 30s who went to a martial arts practice session without his inhaler. He suddenly developed an exercise induced asthmatic attack. By the time the ambulance and paramedics had arrived he could not be revived and passed away. Prompt use of an inhaler would most likely have circumvented this. A similar situation could just have easily occurred with cosmetic surgery.

I was performing non-cosmetic reconstructive surgery on a healthy 20 year old patient in the hospital. He was asleep on the table and just as I was about to make the first cut the monitors showed the oxygen in his blood suddenly dropped to dangerously low levels. Anesthesia went into action and gave him a bronchodilator using an inhaler via the breathing tube. He rapidly responded and the oxygen came back to normal levels and was maintained there using intravenous medications. In a non-accredited operating room lacking all of the necessary equipment and medications that patient would have been in real deadly trouble. There is a good chance he would not have survived a liposuction procedure under local anesthesia in a non-certified operating room. Furthermore, that patient was previously thought to be healthy and had no previous history of asthma.

The botulinum toxin is widely recognized for its ability to decrease the appearance of wrinkles in cosmetic surgery. What many people may not know is that it also has a number of health benefits as well. Hospitals in India are currently using the drug as a treatment for cancer patients who have lost their voice due to throat cancer. Patients undergoing cancer treatment undergo a removal of the voice box as a part of the treatment necessary to remove the cancer.

Tata Memorial Hospital is one hospital that is currently performing the procedure on patients who are suffering with severe voice problems after cancer treatment. The treatment helps patients that are unable to benefit from an artificial voice box. For some patients, the treatment helps patients produce sound after doctors remove the voice box due to cancer. Ninety percent of patients who undergo the removal of their voice box will be treated successfully with an artificial voice box. For the remaining ten percent, the voice box does not restore sound.

The treatment is done by injecting the chemical directly into the vocal chords that will help in the muscle relaxation in order to relieve problems such as difficulty in speaking, stammering and strangled quality of voice. The frequency of the dosage required is determined by the doctor after a post-treatment checkup.

Patients must undergo tests to determine the cause of the prosthesis failure. If it is determined that a hyperactive or hypertonic pharyngoesophageal segment causes the artificial voice box failure, the Botox injection procedure can take place. The physician must also determine the length of the hypertonic segment. The injections are made into the segment at 1 cm intervals. Patients may see results in as few as 12 hours after receiving Botox injections.

Botox injections can also treat patients without cancer who have lost their voice because of laryngeal dystonia which causes the vocal chord to spasm. Physicians inject Botox into the muscles that surround the voice box to relax the muscles and allow vibration and sound to occur.

Botulinum toxin has been studied for more than 100 years and in the last 20 years a number of health issues have been treated with the neurotoxin. Botox has been used to treat cervical dystonia, muscle spasms, muscle pain and underarm sweating in addition to the treatment for voice box problems. There are currently 21 medical uses for the neurotoxin in 80 countries, with research continuing to uncover possible new uses.

A Google search on "home laser" yielded 154,000,000 website links overseas and 48,000,000 when searched in the US. Most of the initial listings are for hair removal devices but there are also ones for treating acne and for facial rejuvenation and others treat skin conditions like psoriasis, vitiligo and dermatitis. Many of these home laser and light or ultrasonic devices can be purchased on the Internet. Sellers tout the benefits of these products in treating acne, age spots, large pores, wrinkles, sagging skin, puffy eyes, rosacea, cold sores, and many other skin conditions. However, few of the devices have been studied or approved by the Food and Drug Administration. Some of them sound sort of scary and could be a waste of money or at worst harmful. Sales of home cosmetic devices totaled $500 million last year, and are expected to nearly double to $950 million in 2015. Women have been removing hair from their legs for quite some time. Now it is a multibillion dollar per year industry.

These new home devices tend to fall into four categories:
Diode or intense pulsed light devices that target hair removal,Light-emitting diode (LED) or heat devices that claim benefits for acne treatmentRejuvenation devices to treat wrinkles using laser or infrared light Home phototherapy devices that provide UVB light.Home devices use lower fluences and longer pulse widths (lower power and less penetration), compared with office-based treatments.

Hair Removal Devices
To be effective, energy in the form of heat must be absorbed by the hair shaft, penetrate deep enough to affect the follicle or root of the hair, and be administered quickly enough to stop transference of the heat to skin surrounding the hair follicle and shaft. Since hair grows in cycles and is most sensitive to treatments during the active growth cycle, it takes several laser treatments to remove hair for good. All of the devices work best and are safest on dark hair in the presence of light skin color.

One of the first home laser devices to be studied was the Tria diode laser.

Studies showed average hair reductions of 60% at 1 month, 41% at 6 months, and 33% at 12 months after three home treatments in 77 appropriate users (Lasers Surg. Med. 2007;39:476-93). In another study 86 percent of patients experienced more than 30 percent hair reduction, and 38 percent had more than 80 percent hair reduction at one year after the last of 8 monthly treatments. Hair removal was complete for 31 percent, and of those who experienced regrowth, 69 percent reported that the hair was finer and lighter than before treatment. A skin color sensor blocks the device on darker skin colors otherwise these individuals will form skin blisters. The FDA approved the device for off-face use; it costs approximately $395.

The Silk’n SensEpil by Sephora uses intense pulsed light at low energy and short pulse durations. It also has a built-in Skin Color Sensor that locks the device on darker skin tones.
It is FDA approved for use on skin on or below the cheeks, it costs approximately $499 plus the price of disposable parts. Three studies in 34, 20, and 10 females, respectively, found it works best for thin hair on the legs and arms, and is less effective for hair in the armpit or groin areas (J. Cosmet. Laser Ther. 2009;11:106-9; Dermatol. Surg. 2009;35:483-9; and Lasers Surg. Med. 2010;42:287-91).

The No! No! Hair device uses patented Thermicon technology employing a thermal filament to deliver heat to the hair shaft without a light so they claim it is safe for all skin and hair colors.

It is the most heavily advertised hair removal device at least on late night television. In a study of 12 patients, twice-weekly treatment for 6 weeks with the low-energy device removed 44% of hair on the legs and 15% of hair in the bikini area at the 12-week follow-up (J. Drugs Dermatol. 2007;6:788-92).

In another study of 23 patients (7 men, 16 women) aged 18-55 years two sites on one leg of each patient were shaved 4 days before baseline, and then were treated every 3-4 days with the No! No! device on one site on the leg and by shaving the other site for 8 weeks. There was no significant difference between the 2 areas in terms of number of active hair follicles, hair regrowth, thickness or color after 1 month. That is to say singing the hair away with the device was no different than shaving it off. The No! No! device is basically an expensive razor.

The No! No! costs approximately $270.

Devices to Treat Acne
Eight studies since 1999 have shown that doctors' office treatments with blue light are effective in eliminating Propionibacterium acnes bacteria the causative agent of acne. Just clearing the bacteria isn’t enough a lot of the time because the bacteria produce irritating proteins that can be left behind so additional medical treatment with prescription or over the counter medications is frequently required. The Tria system comes with washes and topical creams, or patients can use the device with whatever prescription regimen they are on.

Four home devices now offer self-application of this blue light. The power density of the various devices makes a difference. Lower power density requires twice-weekly, 20-minute applications on each side of the face, which can be difficult for patients to do. Higher-density blue light devices, such as the Tria skin clarifying system, require less than 3 minutes twice a day.

The TRIA Skin Perfecting Blue Light uses blue light to kill bacteria in the pores thereby unclogging the pores and eliminating break outs.

Studies have showed 70% clearance of treated areas within 2 weeks. A company-sponsored study of the Tria device in 33 adults showed significant reductions in inflammatory acne lesions after 3 weeks of treatments (J. Drugs Dermatol. 2011;6:596-602). The device's blue light cartridge has to be replaced about every 2 months. The FDA approved the device for the treatment of acne, it costs approximately $245.

The No! No! Skin uses heat generated by light to treat acne. A green light releases oxygen from porphyrins produced by the bacteria to kill the bacteria. A red light diminishes pain and swelling.
It also costs about $270.

The Claro home device by Sephora
 combines heat and intense pulsed light:
-Blue Light (400-430nm): stimulates the production of oxygen, which attacks the bacteria that causes acne
- Red Light (600nm): combines with heat to soothe the inflammation, redness and soreness of each pimple while accelerating the healing process 
- Infra-Red Energy (700nm): creates heat that helps to kill the acne bacteria while increasing the effectiveness of blue light
It costs approximately $195 and comes in 3 colors - red, black and blue.

ThermaClear Acne Clearing Device delivers a 2-second pulse of targeted heat to each pimple to kill acne causing bacteria.
It's FDA cleared and advertised as safe and effective on all skin types and tones.

Zeno uses the combination of a topical medication containing 1% salicylic acid and skin moisturizer followed by the application of a small vibrating heat generating hand held device to treat acne.
At $40 it may be the cheapest device available.

Skin Wrinkle Removal - Rejuvenation
The PaloVia fractionated laser (Palomar Medical Technologies) was the first FDA-cleared at-home laser for treating wrinkles around the eyes.
There are two phases to the wrinkle treatment plan – the Initial Phase of one treatment per day for 30 days and the Maintenance Phase of one treatment 2 times per week. It costs about $500. A blinded study of 34 subjects presented at the 2010 meeting of the American Society for Laser Medicine and Surgery reported a 1-point improvement on the 9-point Fitzpatrick wrinkle scale in 90% of patients after 4 weeks of daily use and in 79% after 4 weeks of twice-weekly maintenance treatments.

Phototherapy

The Levia UVB device (Lerner Medical Devices) is approved for home use to treat psoriasis, vitiligo, and atopic dermatitis.
It directs concentrated ultraviolet B (UVB) light, which has a long history in treating psoriasis, to psoriasis plaques. The treatments require a prescription and programming of the device. Multiple studies have shown that home UVB therapy is as effective as office treatments.

I have not covered the scarier sounding devices in this blog. In conclusion I think we will see doctors doing laser hair removal as a thing of the past. It makes we wonder if the home laser tattoo removal kit is just around the corner.

Anyone watching television lately has been exposed to a mass marketing blitz by Lifestyle Lift. The infomercials claim over 150,000 completed surgeries and are filled with satisfied customers who in before vs. after photos look remarkably younger and happier after surgery. In 2012, Grammy®-winning singer, author, and television personality Debby Boone, best known for her 1977 RIAA Platinum-selling #1 hit "Theme from You Light Up My Life," became the spokesperson for the company in its television commercials and its half-hour infomercial; the song is well-represented in both the commercials and in the infomercial.

The ads promise “minor one-hour procedure with major results designed exclusively to improve jowls, frown lines, wrinkles, loose neck, and facial skin” that "requires no dangerous general anesthetic” and you can “return to work quickly compared to a traditional procedure.” They boast locations across the nation – in 42 cities and 22 states. The concept that is conveyed in this marketing is that this procedure is equally effective regardless of the surgeon doing it. Lifestyle lift is the company's name and is also a trademarked brand name used to market the procedure of the same name. Doctors sign up with the company and give a percentage of their fee to the company for performing their advertising. Prospective patients call the company or go to its website and are then referred to a nearby participating surgeon. The procedure itself is performed under local anesthetic and generally costs half the price of a regular facelift. Patients are lured in by the mass marketing, price and use of local anesthetic without general anesthesia (which is presumed to be riskier than local anesthetic). The model is high volume, low cost facelifting.

A regular facelift involves making an incision around the ear lifting or dissecting the skin off the underlying soft tissue in the neck and almost to the corner of the mouth. A variety of techniques are then employed to lift this deeper soft tissue of the cheeks and neck and the excess skin is removed from around the ear to yield the least noticeable skin scar, one that is hidden in the natural creases around the ears. Over many years after cumulative experiences of surgeons worldwide this became the standard facelift which gave the most reliable and longest lasting result.

Over the last few decades further modifications have been applied to the process to individualize it since no 2 people age exactly the same way. Beginning in the 1990s younger than previous patients began requesting the procedure. In these cases less aggressive surgery or only parts of the original procedure were necessary. The s-lift was born. In this procedure an s-shaped incision is made in front of the ear that extends under and in some cases around the back of the earlobe. The original s-lift involved a skin incision in front of the ear only and excising-suturing a deeper layer of tissue to give a tightening effect without elevating much skin as a separate layer by itself. The original procedure had little or no effect on rejuvenation of the neck. This was later modified by a number of physicians to include numerous different variations of the original procedure including pulling the deeper tissue upward using a suture tightened around the cheek bone. All are basically minor facelifts performed without doing all the steps of a full face lift. I personally do not use this misleading nomenclature as it gives rise to prospective patients asking for a specific procedure rather than asking for resolution of a specific cosmetic issue they want addressed. It has also facilitated incompletely trained or incompetent physicians to advertise their performance of specific procedures. They are incapable of going over the different procedures available with the patient much less performing those procedures. The lifestyle lift is basically an S-lift procedure with a neck tightening component including suturing tightening of a muscle in the neck. Instead of extending the skin dissection towards the mouth it is stopped a short distance from the ear and sutures with or without excision of deeper tissue near the ear are used to get a transmitted lift or tightening towards the center of the face beyond where the cuts are made. Other similarly trademarked lifts have appeared including "Quicklift", "The Weekend Facelift”, “The MACS Lift" etc. but none has been advertised to the extent of the Lifestyle Lift which has turned the procedure into a multimillion dollar business.

Almost since its inception LifeStyle Lift has been involved in multiple lawsuits. At one point the company sued Realself who had posted negative reviews as well as some positive reviews from LifeStyle Lift patients on their website. The allegation was that Realself infringed their patent by including the LifeStyle Lift name in their URL. Lifestyle Lift tried to use trademark law to wipe the negative reviews off RealSelf and keep them from influencing prospective consumers. Realself counter sued LifeStyle Lift for their employees allegedly placing false positive reviews on the Realself website. That case was settled with confidentiality agreements. Another company was sued by LifeStyle Lift for posting negative reviews on a webpage using a URL containing the term LifeStyle Lift again alleging patent infringement. The judge who heard the case dismissed it on May 2, 2008. In 2009 Lifestyle Lift reached a settlement with New York state over claims it had employees post false customer endorsements on third-party websites, including RealSelf.com, and on some 10 websites the company had created to appear as consumer generated praising of the procedure. Lifestyle Lift was ordered to pay $300,000 dollars to the state, and it agreed to cease the practice. In 2010, the Florida's attorney general office received more than 60 complaints about the company, including several contesting its claims about fast recoveries, minimal pain and results that take years off one's appearance. The office then opened an investigation to determine whether Lifestyle Lift's marketing practices constituted deceptive advertising by claiming its procedures were safer, less expensive, with faster recovery times than other types of facelifts. According to USA Today, Lifestyle Lift's advertising used the term "revolutionary" to describe a variation on longstanding face-lift procedures since the LifeStyle Lift did not really involve any new procedure other than the mass marketing of facelifts. In 2008, an Orlando, Florida facial plastic surgeon filed a complaint with the Florida Board of Medicine, seeking payment for emergency room services he provided to a Lifestyle Lift patient; the company denied that it was negligent in the case. The patient was "bleeding from the face" and needed emergency assistance with breathing and surgery for hematomas. The patient, who settled a lawsuit against Lifestyle Lift out of court, was in intensive care on a ventilator and breathing tubes for six days. Since the complications were the result of cosmetic surgery her insurance presumably did not cover the emergency room care, the surgeon was forced to treat the patient by federal laws and she likely had no more money after the lift procedure so the surgeon could only get reimbursed by LifeStyle Lift. In July 2009 a Massachusetts woman had a seizure during the procedure presumably from the local anesthetic injection, was not hooked up to any continuous-monitoring equipment during the procedure, and no anesthesiologist was present. The medical staff did not know immediately how little oxygen she was getting. Forty-eight minutes after her first injection, the staff called for an ambulance. She was taken by ambulance to Mount Auburn Hospital in Cambridge,Massachusettes where her heart stopped twice and she was diagnosed as brain dead; she was deprived of oxygen for far too long. Her family took her off life support a week later and is now suing for wrongful death.

Now that there is blood in the water the sharks are circling and Meyerkord & Meyerkord, a St. Louis based personal injury and medical malpractice law firm, announced it is currently investigating claims related to the Lifestyle Lift® cosmetic procedure in pursuit of a class action lawsuit.

A Fort Myers, Fla., facial plastic surgeon, says he's treated several patients who were unhappy with the results they got at Lifestyle Lift. Most had "visible, poorly executed face-lift scars with no discernible aesthetic improvement," he says. USA TODAY interviewed six other plastic surgeons who did not want their names used but made similar comments.

Although a min-facelift, LifeStyle Lift or other type of lift, may appropriate in some patients it is not appropriate for all patients just as local anesthesia alone is not appropriate for all patients. The highly variable reviews of the LifeStyle Lift could be due to a one size fits all approach (the procedure is not for everyone), false positive reviews by the company (as they have a history of doing so), differences between actual surgeons or some combination of the above. The ads would have you think that all surgeons performing a LifeStyle Lift and advertised on their website are the same but we all know that is not the case. It is the surgeon that is important not the name of the procedure performed or machine used at surgery just as it is the tennis player not the racquet that wins the tennis match.

Critics call this the commoditization of cosmetic surgery. Procedures that once included lengthy consultations with plastic surgeons and trips to the hospital, now often involve meetings in office-park surgery centers with salespeople who tell prospective patients what "work" they need and how little it can cost when performed in their offices as opposed to a private plastic surgeons office. The patients are pulled in by aggressive marketing programs on television the internet etc. This started some years ago with hairgrafting in the Bosley clinics and has spread to liposuction, facelifts, laser treatments and god knows what else. Proponents claim this way of doing plastic surgery allows those who otherwise would not be able to afford it to undergo cosmetic surgery.

While these clinics may employ plastic surgeons who are either board-certified or up for certification, lawyers, victims and other plastic surgeons say these new-style surgery clinics are under so much sales pressure they often don't sufficiently screen patients for medical problems, do inadequate follow-up and persuade patients to undergo procedures that are either unnecessary or unlikely to get good results. The surgeons work there because they have few other options in a long term recession where few have access to money and their case loads are disappearing to these heavily marketed companies offering steeply discounted procedures. I have personally witnessed this with one company who offered to hire me for liposuction procedures under only local anesthesia but would not let me see the facility until I signed a non-disclosure agreement. The facility had poor patient follow up, substandard operating facilities lacking emergency equipment, inadequate consent forms and other paperwork and high rates of patient dissatisfaction requiring revision. When I broached some of these issues I was suddenly persona non-grata and none of my calls or emails were answered. After some prodding they told me the job opening had basically dematerialized.

3 business models have arisen in this commoditization process. The first involves the surgeon working in the companies facility as an employee as in the Bosley model for hairgrafting and the Sono Bello model for liposuction. The second involves the surgeon using their own office to see referred patients like the LifeStyle Lift and Vampire Facelift. The third involves the company referring patients and stationing their own employees in the doctor's office like the American Laser Clinics. The end result to the practice of Plastic Surgery though is just as destructive.

Lupus is a rheumatic condition which affects the muscles, joints, and connective tissue. About 1.5 million people in the US have lupus which includes as many as 10,000 children. Nearly 90% of those diagnosed with lupus are female. It's an autoimmune disease. A healthy immune system produces special proteins or antibodies and these normally protect the body against bacteria and viruses that cause infections. In the case of lupus, the immune system confuses the body's healthy cells and sees them instead as if they were a bacteria or a virus, and the result is that our antibodies then attack some of our own body's healthy cells. You become allergic to yourself.

So, what causes lupus? The cause is unknown although genetic factors may be important. Certain things can trigger the disease such as infection, medications, and even extreme physical or emotional stress. There are different types of lupus; the commonest is something called systemic lupus erythematosus or SLE and this affects multiple organs, and there is also form known as discoid or cutaneous lupus which only affects the skin, and in as many as 10% of all lupus cases, they're classified as drug-induced lupus.

Systemic Lupus Erythematosus (SLE) is an autoimmune disease where self generated antibodies attack different organs systems in the body including blood vessels, liver, eyes, kidneys, joints, heart, heart valves, skin, lungs, brain...and/or form complexes with their protein targets (antigens) that damage these organ systems. The degree of damage to each organ system is highly variable. Arthritis and joint pain is the most frequent complaint. It is thought to be due to a genetic predisposition combined with viral infections. The disease can spontaneously remit, respond to corticosteroids or be unresponsive to available medications. 50% of those with SLE have some degree of heart and/or kidney involvement. Much of this organ damage can be masked and then suddenly become apparent especially during flare ups of the disease. I am aware of one women in her 30s who died in the recovery room after breast augmentation by another surgeon due to a heart attack caused by SLE induced damage to her coronary arteries.

So, what are the symptoms that are commonly associated with lupus? There are many. Classically, there will be butterfly rash. This is a rash that is across the cheeks and the bridge of the nose. There may be sensitivity to light that results in a rash. Also there can be ulcers in the nose or mouth, which are usually painless. There's a long list of many other symptoms that are associated with lupus including things like arthritis, inflammation of the lining around the organ such as the heart and the lungs, kidney problems. There may also be neurological disorders including problems with seizures or even psychosis. Blood problems and problems with the immune system are also found in lupus. And in addition to that, there are some nonspecific symptoms such as fever, weakness, fatigue, and weight loss. There is no known cure for lupus but the symptoms can be controlled with drugs, for example steroids, and sometimes more aggressive treatment is needed with immunosuppressive therapy.

Therefore it is imperative if you have systemic lupus that you have a complete examination of all major organ systems before undergoing any elective cosmetic surgery. This may include cardiac stress testing and blood tests for liver and kidney function. If you cannot be weaned off of prednisone that may be an ominous sign and may preclude any elective cosmetic surgery especially if any implants are involved.

If you are taking prednisone for lupus the medication can also prolong the healing time after surgery and weaken your ability to fight infection so proceed with caution before undergoing any elective cosmetic surgery.

For detailed information, support groups and to live the fullest life that you can with lupus visit the Lupus Foundation of America and the Lupus Research Institute.