SACRAMENTO, CALIF. After a decade-long struggle to gain specialty board recognition in California, the American Board of Cosmetic Surgery (ABCS) recently won its petition in a lawsuit against the Medical Board of California. As a result, board-certified cosmetic surgeons in California will be allowed to refer to their board certification in cosmetic surgery in advertisements and in telephone listings.

The ABCS first filed its application for specialty board equivalency recognition with the Medical Board of California in the mid-90's, which was denied in 1997. The ABCS submitted the current application based on its new certification requirements.

Following two presentations by the ABCS, the Medical Board of California rejected the organization's follow-on application without stating its reason. The ABCS subsequently filed suit in the California Superior Court against the Medical Board of California and the State. In September, the Superior Court directed the Medical Board to grant ABCS's application for equivalency.

In 1979, the ABCS was established to test and verify legitimate training and experience by surgeons performing cosmetic surgery. Most training in cosmetic surgery is postgraduate, occuring after a surgeon has obtained specialty certification by a separate American Board of Medical Specialties (ABMS).

According to Robert Jackson, M.D., ABCS president, theirs is the only board that evaluates cosmetic surgeons.

"Only ABCS certification represents a surgeon's education and experience in the cosmetic surgery specialty," he says. "The court ruled in our favor because our certification requirements meet or exceed the ABMS's and satisfy California's statutory requisites," he concludes.

Toronto: Breast augmentation combined with mastopexy can yield long-lasting results depending on the technique that is used, explains a plastic surgeon here.

Speaking at the annual meeting of the Canadian Society for Aesthetic (Cosmetic) Plastic Surgery (CSAPS), Brian Peterson, M.D., a plastic surgeon based in Kelowna, British Columbia, Canada, and a clinical instructor in the department of plastic surgery and faculty of medicine at the University of British Columbia in Okanagan, British Columbia, describes how he performs the procedure to correct sagging breasts and give breasts a more youthful appearance.

SHAPE AND POSITION "The augmentation is to enhance the shape and fullness of the breast, and the mastopexy is to reposition the nipple-areola complex to a more elevated and youthful position on the breast," explains Dr. Peterson, current CSAPS president.

OPTIMIZING THE STANDARD With the standard operation, Dr. Peterson says that the skin envelope that holds the breast tissue in place is tightened, but that the procedure is a temporary fix and that gravity has a downward pulling effect.

"With gravity, the breast will sag over time," he says. "The tissue would be sagging off of the implant in five years. If we just augmented the breasts, they would end up bigger and saggier in the long term. I don't think that is the appearance that women desire."

In Dr. Peterson's operation, he places saline implants underneath the pectoralis muscles. During the breast lift component, he removes a moderate amount of breast tissue when elevating the nipple-areola complex. The glandular tissue that is being resected would sag in the future, so this technique avoids potential sagging, giving a more youthful result in the long term, Dr. Peterson says.

To perform this procedure, he makes a longer incision around the nipple-areola complex, which results in a greater scar running around the nipple-areola complex and running vertically down the lower pole of the breast, likening the scar to that which appears in breast reduction. Surgeons would choose an implant size in keeping with the amount of breast tissue that is being resected, Dr. Peterson explains.

"If you see someone pre-operatively and plan to take off 100g to 150g of breast tissue, I would then use an implant that is 150 cc's larger than what we initially size for the patient," Dr. Peterson says.

The technique is not difficult to perform for surgeons who regularly perform breast augmentation, according to Dr. Peterson.

"There are no more challenges to this than in learning any other new procedure," he says. "There is a learning curve to any new technique."

TECHNIQUE TRADE-OFFS He estimates recovery at approximately 10 days compared to two to three days for a standard procedure. He adds that it takes up to a year for the scar to fade with his procedure.

"You do see a more visible scar with this procedure. There is a more limited incision with a standard breast augmentation. However, the results that are achieved are more consistent," he says.

In terms of general contraindications, heavy smokers are excluded as surgical candidates. Dr. Peterson notes that any operation that is done on the breast can affect nipple sensitivity, but that in the vast majority of instances, the sensitivity is recovered over time.

"If nipple sensitivity is an important aspect of the patients' sexual life, and it would be greatly affected if they didn't have that sensitivity, then doing an operation would be something to re-think," he notes.

SUPPLEMENTARY PAIN DATA On an adjunctive note, in a prospective series of breast augmentation cases published in Plastic Surgery in 2004 by Dr. Peterson and his colleagues, the investigators found that there was a trend to less postoperative pain and less time spent recovering with the use of ketorolac and bupivacaine compared to ketorolac alone or bupivacaine alone in 100 patients who underwent retropectoral breast augmentation.

For more information
Brian Peterson, M.D.
peterson@okanaganhealth.ca

Quezon City, Philippines Patients born without dimples in their cheeks or whose dimples have faded as they grew older now have a surgical option available to create or restore that special attribute emblematic of a youthful appearance.

Using a straightforward outpatient procedure, physicians can create facial dimples for those patients who desire them. Although not commonly performed in the United States, facial dimple creation has found favor in other parts of the world.

Dimples, those indentations of the skin caused by an attachment of the skin to underlying muscle tissue, are common in babies and young children, but tend to diminish or become less noticeable with age as the underlying muscles stretch through use. This pattern of appearance contributes to the association of facial dimples with youthfulness.

Dr. Lasa has performed the facial dimple creation procedure since 1987 on patients ranging from 18 to 50 years of age — perhaps interestingly, on approximately equal numbers of men and women. Although it can be combined with other cosmetic procedures, Dr. Lasa reports that his patients who desire dimple creation usually request only this one procedure.

"Asians find this an attractive facial feature," he says.

DIMPLE CONNECTION the key to the creation of a facial dimple is to create an attachment between the skin and the cheek muscle underneath. with this attachment successfully in place, contraction of the muscle will result in the presence of a dimple.

"A punch biopsy instrument is placed against the buccal mucosa and circular motions are made to cut through the mucosa, submucosal fat, and cheek muscle," Dr. Lasa says. "A circular core of these tissues is removed, leaving the skin intact, which will create a shallow cylindrical-shaped defect under the skin."

"This 'defect' then is closed by placing an absorbable suture through the cheek muscle on one side of the defect, then through the dermis layer of the skin, and finally through the cheek muscle on the other side of the defect," Dr. Lasa says.

"A surgical knot is tied, which, in turn, will result in dimpling of the skin even without smiling."

As the suture is absorbed the dimple will flatten out, according to Dr. Lasa. This process will usually take a week or so. As the site heals, internal scarring resulting from the presence of the suture will connect the skin and muscle, creating the dimple.

NATIONAL REPORT Experts weighing in on the advantages of silicone gel versus saline implants offer equivocating observations. Some say silicone gel breast implants represent a welcome option for informed patients, while others question whether manufacturers have adequately studied silicone's potential risks. Experts also point out that saline isn't going away; some patients will continue to prefer it over silicone.

In November, the Food and Drug Administration (FDA) approved the marketing of silicone gel-filled breast implants made by Allergan Medical (formerly Inamed) and Mentor for breast reconstruction in women of all ages and for breast augmentation in women ages 22 and older.

An FDA press release states, "Now that the products have been determined to be safe and effective, the FDA will continue to monitor them." The FDA is requiring manufacturers to study 40,000 women for 10 years post-implantation (and to continue core studies for 10 years). At the same time, the products' labeling emphasizes risks including rupture and the need for MRIs starting three years after implantation and every two years thereafter.

Dr. Rosenberg

Availability was never intended to mean silicone gel implants will suit all patients, he adds. Rather, Dr. Rosenberg says that the availability of silicone implants "empowers women to make well-educated choices and keeps the decision between patient and physician."

Dr. Berman

"Silicone implants are much more natural, and women tend to like them better," he says. Some women have "gotten it in their heads that silicone is somehow dangerous, so they prefer saline. But in all honesty, if a silicone implant were to rupture, the woman would still preserve her breast mound" while awaiting repairs, whereas the body resorbs saline, adds Dr. Berman.

Nevertheless, some sources are approaching silicone implants with great caution.

"Will I now change to all silicone implants? Absolutely not," says Rod J. Rohrich, M.D., professor and chairman, department of plastic surgery, University of Texas Southwestern Medical Center, Dallas.

Dr. Rohrich