Vancouver, British Columbia — Results from an online survey of the experiences of women with breast implants suggest that overall, silicone gel implants are somewhat comparable to saline implants — although for natural feel, silicone scored higher.

According to C.B. Boswell, M.D., a practitioner in St. Louis and one of the study's authors, women with both types of implants expressed high levels of satisfaction with their procedures. The studies were funded by the Aesthetic Surgery Education and Research Foundation and were carried from 2001 to 2002 in all U.S. states and most Canadian provinces.

Methodology The primary online breast augmentation survey of women with and without implants was posted on http://www.implantinfo.com/ for six months. Some 2,273 women with implants and 1,736 without implants responded to the 177-question survey. The responses of the women who had received implants were compared with those of women considering the procedure.

Nearly 14 percent of the women had gel implants and 86 percent had saline implants.

"Women with saline implants were much more likely to say that augmentation with saline implants completely met their expectations — 51 percent of the saline group versus 41 percent of the gel group, on a 1-to-4 scale," reports Dr. Boswell. "However, the statistical difference disappeared when we looked at the top two groups (mostly and completely satisfied — 88 percent for saline and 85 percent for gel). Another way that we looked at patient satisfaction was to see if patients would recommend augmentation to their friends and family. Overwhelmingly, patients would recommend breast augmentation (95 percent of saline and 90 percent of silicone gel implant recipients).

Some 13 percent of the respondents had undergone at least one revision surgery, and women who changed their initial saline implant for a gel implant expressed much higher satisfaction on all measures than the gel-to-saline group.

There was no significant difference in breast pain frequency in the two groups.

Tactile marks "The area where the silicone breast implant was substantially better than the saline-filled implant was when the patients rated the feel of the breast," Dr. Boswell notes. On a 1-to-5 scale, with 5 representing a natural feel to the breast, gel implants were significantly more likely to achieve this level. The same response also occurred with the level 4 ranking.

Pain, discomfort Another group of 1,700 women who had never had breast augmentation were compared with a gel implant group who were about 10 years older, on joint pain, muscle aches and weakness, fatigue, dry eyes and mouth, and numbness and tingling.

"What is really interesting is that the group of women who had never had any implants — 1,700 women — were much more symptomatic than the implanted group. And this was statistically significant in all nine symptoms that were compared," Dr. Boswell says.

In the augmented group, joint pain, joint swelling, muscle aches and dry eyes were all more prevalent in the pre-augmentation phase than post-operatively. Joint pain, joint swelling, muscle aches and fatigue occurred twice as often in the gel group as in the saline implant group.

The women were also asked, in an open-ended question, what they thought caused the symptoms they had reported. Of 378 respondents, only 14 with saline implants and two with gel implants attributed the symptoms to their implants. Others gave reasons such as injuries, fatigue, job stress and medications as possible causes.

Diseases The researchers also investigated diseases associated anecdotally with silicone gel implants.

As the gel implants were almost five years old, as compared with the saline implants that were approximately one year old, the data needs to be interpreted with caution, advises Dr. Boswell.

The following diseases were considered:

• rheumatoid arthritis
• osteoarthritis
• lupus
• scleroderma
• Sjögren's syndrome
• fibromyalgia

Sonoma, Calif.— Want to attract new patients but don't have the staff to adequately handle their inquiries? A new type of business promises to bring more patients into your office.

How it works This is how it works: You have taken training courses, learned new procedures and reorganized your practice to offer them. But demand isn't building as you had hoped. To get the word out, you advertise with a local newspaper or radio station. The tag line is your office number.

Or maybe she jots a note in her calendar and places the call. The harried young man who answers the phone has a job description a mile long. He doesn't have time to answer her questions. Frustrated, the prospective patient hangs up without making an appointment.

Services such as Patient Link recast the scenario. During lunch, evenings, weekends and whenever things get too hectic, your receptionist can forward calls to a tollfree number. A customer service representative will answer, click on a description of laser hair removal, describe the procedure using a script you've approved, then set up an appointment for a consultation.

What's the bottom line?

The bottom line in evaluating such services is cost and closing rate (percentage of calls from prospective patients converted into appointments).

The system uses existing phone lines and computers, so no new equipment is required. All Patient Link plans begin with a $1,000 set-up fee to customize your Web-based interface with information about each physician — bios, procedures performed, a description of each procedure and costs.

Patient Link offers a basic service at $495/month for 240 minutes of talk time. The premium service is $1,295/month for 1,200 minutes.

With LASIK, a service previously launched for ophthalmologists, Mr. Atwood says, "We have a closing ratio of 50 percent or better."

What's the average closing rate for U.S. cosmetic surgery and dermatology practices? Mr. Atwood doesn't know, but he suspects it could be as low as 10 to 20 percent in some practices.

"Sometimes the office staff is too busy to even get back to their voice messages," he notes.

Most sense Call centers are not suited for every practice. For instance, established, busy practices may have little need for such a service. Small practices will experience a longer payback time and higher cost per new patient. The service is not suited for episodic use due to the $1,000 set up fee.

According to Mark Ray, vice-president of practice development at TruVision, the service makes the most sense for "practices that are going after new patients or that want to advertise new elective procedures."

Figuring out how to coordinate scheduling can be challenging.

"There are about a hundred different practice management software systems," Mr. Atwood says. "It is almost impossible to directly interface with all of them."

TruVision settled on an indirect system of linkage. Users login to access a proprietary Web-based scheduling system. Office staff open or close appointment slots designated for use by customer service representatives. The program automatically notifies staff when an appointment has been made or when the number of available slots dwindles.

Importantly, says Mr. Atwood, the program provides subscribers with performance statistics: the name of the caller, the time of the call and whether an appointment resulted.

Colorado Springs, Colo.— Spas aren't just for pampering patients. Increasingly, medical spas are considered a crucial component for maximizing results of cosmetic procedures.

Dr. Saltz

Dr. Saltz says, "I always wanted a place where my patients could be taken care of in the early postoperative period. For example, if you do liposuction, they are swollen and bruised. We have some superb lymphatic drainage massage therapists here in our clinic. So, the second day after surgery, they start opening the lymphatic channels and helping the lymphatics to drain all the swelling. Having a medical spa component to the practice has helped the patients a lot in the immediate postoperative period."

"If a patient has a facelift today," he explains, "she'll come back in 48 hours to get her face massaged. She'll also have some makeup done so the bruising will be hidden. Patients love that. Psychologically, it helps them a lot. Physiologically, it helps, too, because there's less swelling, bruising, edema and pain. It all goes together. So some of us are incorporating these medical, nonsurgical treatments for our surgical patients with very good results."

He offers the following guidelines for setting up in medical spa:

1. Keep staff in the clinical loop

"It's important they understand that this is really related to your practice," Dr. Saltz explains. " They're here to help my patients before and after surgery. Before surgery, we start treating their skin and preparing them for surgery. If they're going to have a major liposuction, they'll go through a nutritional consultation, and they'll start exercising. Then, after surgery, you can improve their swelling and bruising, and you go back to the skin care and nutrition issues so you not only enhance the results but help maintain them."

2. Capitalize on synergies

In this regard, he says, "My clinic is on one side of the building and the medical spa is on the other." This way, a patient returning one week post-procedure for a checkup can then immediately be whisked into a treatment room for a lymphatic massage.

"It allows us to do this back-and-forth flow," Dr. Saltz says. "Also, the massage therapist has been in the OR and watched the operation. So they're very familiar with what happens."

In fact, all of the spa's therapists (certified massage therapists, certified lymphatic drainage therapists, makeup artists and master aestheticians) observe procedures in the operating room. Therefore, they are knowledgeable in all plastic surgical procedures, invasive and noninvasive, and can better treat, advise and watch for potential complications with patients.

3. Be hands-on

"Patients will come to your spa if they know there's a doctor around," Dr. Saltz notes. "It's a unique situation here in Utah, because there's probably no other medical spa with a plastic surgeon around. Your credibility is right on the line. And you need to be involved 100 percent. So if you want to start (a spa), I strongly recommend building all the attributes of the medical spa around your practice and your training in plastic surgery."

4. Educate your community

Patient before and after Sculptra treatments

Sculptra, an injectable poly-L-lactic acid (PLA), is the only FDA-approved filler for treating facial lipoatrophy related to human immunodeficiency virus (HIV), reducing a sunken appearance in the cheek, temple and eye areas.

Dr. Michael Echavez, M.D., a San Francisco-based plastic surgeon, has treated about 400 HIV-related lipoatrophy patients with injectable PLA filler within the past three years, and has also seen the psychological repercussions of lipoatrophy.

Cause uncertain Studies differ on the exact cause of lipoatrophy in HIV patients. Some indicate it's simply an effect of the AIDS infection. But the more prominent theory places the cause on the antiretroviral medications (which have many side effects) used to prolong the lives of those with HIV. Of the 900,000 to 1 million people in the United States who are HIV-positive, it's thought that 50 percent will develop lipoatrophy. The FDA estimates 150,000 to 350,000 patients could potentially benefit from the new treatment.

Quick Read

Dr. Echavez says he has seen his patients' quality of life improve once their facial concavities are corrected. And he believes that Sculptra's FDA approval signifies a positive turn in treating the condition.

"Now that it is FDA-approved, more people will be aware of the product and what it can be used for," he says.

Dr. Echavez has used other fillers to correct facial concavities, such as collagen and Cymetra (LifeCell, Branchburg, N.J.), but found their effects didn't last long. He also uses soft tissue implants, but says they are limited in that they can only treat the upper part of the face, and they require a more invasive and complex procedure to administer.

Longer process Of all the fillers he works with, he says, "At this point, I think that I do prefer Sculptra. The results are natural-looking; there's no recovery period. But there is a longer process involved than with other fillers."

That longer process is due to characteristics specific to injectable PLA, the biodegradable and biocompatible material used in dissolvable stitches and soft tissue implants. Once it's injected, it increases the thickness of the skin in the treated areas, by stimulating the body's tissue to produce collagen fibers, thus improving the appearance of fat loss. However, the process of collagen production is gradual, and it takes longer to see the end result.

Dermik recommends that physicians limit the volume of Sculptra to 0.1 mL to 0.2 mL for each individual injection, adding that in the cheek area, approximately 20 injections might be needed.

Colorado Springs, Colo. — Endoscopic surgery provides a minimally invasive alternative for lifts of the midface, brow and other facial areas, provided doctors adequately address the potential for asymmetry in their results.

"The midface is the hot topic right now in aesthetic facial surgery," says Renato Saltz, M.D., a plastic surgeon in private practice in Salt Lake City and associate clinical professor, University of Utah.

Dr. Saltz

"I come in through an incision in the temporal area of the scalp, and subperiosteally, I dissect down into the cheek area. Then I use needles and sutures to suspend that area, elevating in a superior medial direction to provide a midface lift. When you combine this with a brow lift and lower face lift, it really rejuvenates the entire face," Dr. Saltz says.

Dr. Saltz and his colleagues treated a series of 50 patients with endoscopic lifting and direct needle fixation. The doctors achieved safe and aesthetically pleasing results, with a high level of patient satisfaction continuing three years after surgery (Aesthetic Surg J. 2000;20(5):361-367). In this study, researchers found that subperiosteal lifting with direct needle fixation allows the inferior, periorbital and frontal regions to be more precisely repositioned. The technique, furthermore, eliminated the need for midface intraoral and/or infraciliary incisions for 30 patients who underwent additional treatment of the midface.

The doctors used detailed, preoperative markings to map the location of key anatomical structures and nerve pathways. For patients undergoing extended frontal lifting, Dr. Saltz and his colleagues limited their endoscopic entry points to two temporal incisions placed 2 cm behind the hairline, plus two paramedian incisions at the hairline and at the pupillary axis, and a midline vertical incision. They began dissection in a lateral direction above the deep temporal fascia through the temporal incisions. The dissection proceeded medially along the superior and lateral orbital rim in a subperiosteal plane to provide temporal release. The doctors then dissected the frontal region in a subperiosteal plane and linked both areas through complete release of the temporal crest fascial fusion zone.

Additional steps included releasing the brow and carefully dissecting the glabellar musculature. In the midface area, surgeons ultimately released the insertion of the masseter muscle on the malar bone.

To perform direct needle fixation, the doctors relied on endoscopic visualization for direct observation of their handiwork. Video endoscopy minimizes incisions and bleeding while magnifying images to allow for safer, more precise manipulation of the soft tissues.

The use of tissue glues and early postoperative lymphatic drainage massage appears to reduce swelling and bruising, and minimizes dead space present after subperiosteal release of the midface. The combination of minimally invasive endoscopic surgery and these two additional treatments (glues and early massage) speeds recovery, enhances early postoperative results and, therefore, increases patient satisfaction.

The tissue glue acts in two ways: filling lymphatic channels and reducing bleeding. For such applications, Dr. Saltz prefers fibrin glue and Tisseel (Baxter Healthcare, Deerfield, Ill.). For surgical closures, he usually uses Dermabond (Johnson & Johnson, Piscataway, N.J.). Since this study was published, Dr. Saltz says, the most common adverse outcome he sees is not a complication but a small incidence of early asymmetry that improves over time.

Dr. Saltz has used the endoscopic method for browlifts since 1992.

Boca Raton, Fla. — Blepharoplasty techniques have evolved from those that sought to remove and resurface tissue to those that comprehensively address underlying problems.

"Many of the newer techniques of the perceived problems that occur with aging of the periorbita," says Steven Fagien, M.D., a cosmetic oculoplastic surgeon in Boca Raton, Fla. "It started as a procedure of taking out skin, muscle and fat when blepharoplasty first became popular here in the United States, in part because we saw that we could achieve a sort of cause and effect despite lacking a full appreciation of the ingredients of aging and the characteristics of youth. Someone presented to the surgeon with apparently excess skin and puffiness, and the procedures were based on excision. Patients would even see a big difference after surgery.

"But as time went on and we got a better handle on what happened as the periorbita aged, and what things really looked like in youth, some of the procedures of excision became less acceptable and created more of a change or distortion in the patient's appearance rather than true rejuvenation," he says.

"Problems with lower lid malposition occurred frequently, because no attention was given to the canthus to support the lid to enable procedures to be performed that would be rejuvenative," says Dr. Fagien. "Conversely, surgeons would oftentimes avoid the lower lids or approach the area very conservatively, often removing fat only through a transconjunctival approach, and found those procedures still were not optimal.

Age of lasers "Then the age of lasers came along, and many blepharoplasty surgeons said, 'Now we have a way to make the skin look better.' So fat removal was combined with laser abrasion.

quot;But after all of us went through the phase — in my opinion, a fad — where we were using lasers to improve skin, we shortly realized that not only were the results at times unacceptable or not long-lasting, but this approach also did not rejuvenate in most patients."

At the turn of the millennium, studies began taking an even closer look at how the periorbital area ages.

"It became obvious that it wasn't that things fell, or that we somehow develop excessive soft tissue," he says. "It had a lot to do with reduced elasticity and thinning of the skin, shifts in volume and volume loss, and a loss of adherence of the many soft-tissue layers and the skeletal attachments, and we essentially exhibited what some call 'radial expansion.' Good anatomic studies suggested that if you could address these issues, you may be heading toward true rejuvenation," he says.

New surgical methods To meet this goal, Dr. Fagien pioneered surgical methods for returning the upper eyelid to a more youthful appearance by retaining rather than removing volume, and procedures that rejuvenated the lower eyelid with simple and predictable methods to shape the contours as well as maintain and improve lower eyelid position.

In the latter area, he says, "You need to bolster the support of the lower lid, first and foremost, in order to do the type of rejuvenative procedures — including muscle and skin tightening — necessary to avoid lid malposition. The approach I call 'component blepharoplasty' actually surgically addresses as many of the aging features as possible in order to achieve true rejuvenation.

A patient shown before (left) and after (right) rhinoplasty surgery. Photos: M. Eugene Tardy Jr., M.D., F.A.C.S.

"The most important advance in nasal plastic surgery in the past decade has been an overall significant improvement in the art of diagnosis of small and subtle deviations from normal in the nose," says Dr. Tardy, professor of otolaryngology/head and neck surgery at the University of Illinois, Chicago.

"There certainly have been technical advances as well, but none is as important or as valuable as advances in diagnosis and analysis of very specific deformities in the nose."

Improvements have been made in imaging techniques, as well, including a three-dimensional imaging system with which Dr. Tardy and colleagues are currently working at the University of Chicago. In the future, this imaging system will help cosmetic surgeons understand even thetiniest of details of nasal anatomy before beginning any surgical procedure. It also will allow residents in cosmetic surgery training to perform virtual surgery in real time, helping them visualize how to avoid problems during an actual procedure.

Dr. Tardy notes that skillful surgeons understand how each patient's rhinoplasty outcome is influenced by subtleties and anatomical variants that are properly recognized in an exacting diagnosis.

"An intimate knowledge of the variant anatomy encountered in patients, supplemented by accurate, detailed analytic and diagnostic skills, sets the stage for superior surgical outcomes," he says.

Cosmetic surgeons, he says, must possess and execute a wide range of surgical skills.

"No single surgical technique will suffice to refine every nose to an ideal state," he notes. "Avoid the cookie-cutter approach that so often was a hallmark of the past."

He feels that a rhinoplasty outcome that is individualized to each patient should be "the creation of a nose that draws no attention to itself, but enhances the beauty of the eyes, allows for comfortable nasal function, and is in harmony with the other features of the face."

Attaining such success can be easier said than done. However, Dr. Tardy contends that the past decade has brought improvements in how cosmetic surgeons are trained to appreciate facial balance and proportion and to give generous attention to anatomical subtleties and specific diagnoses.

"We now know that even less experienced surgeons, by attention to these details, can produce very nice results," he says.

In some cases, balancing the proportion of the nose to the rest of the face requires enlargement of the nose, rather than reduction. Dr. Tardy says computer imaging and a discussion of the benefits usually alleviates most feelings of reluctance.

He also warns against artificial implants or substances in the nose to achieve enlargement. Instead, the primary source of reconstructive material should be the patient's soft tissue, bone or cartilage from their nasal septum or external ear.

Dallas — A single treatment with radiofrequency energy provides a safe, non-invasive method for treating mild-to-moderate laxity of the neck and cheeks, said Tina S. Alster, M.D., at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Alster

Performed under topical anesthesia (LMX 5 cream for 60 minutes), the treatment was found to be moderately uncomfortable by most patients, and it resulted in mild, temporary local erythema and edema. However, during follow-up extending 12 months post-treatment there were no scarring complications or pigmentary alterations.

Tissue tightening occurred immediately and continued to increase consistently over the post-treatment follow-up evaluations, reaching a peak at about three months to six months and gradually declining by 10 percent during the next six months. There was appreciable variability in the intra-individual responses, although in general, cheek laxity responded better than the neck, Dr. Alster reports.

"This procedure is not a substitute for a facelift, but with the advantage of having no post-treatment recovery, it is a reasonable option for people in their 40s or 50s with early jowling and/or neck laxity who could benefit from a modest tightening effect," she explains. "In addition, it might also be considered by anyone with contraindications to incisional surgery who is prepared and willing to accept a less than dramatic result."

For treatment of cheek laxity, the radiofrequency energy was delivered to the skin extending laterally and inferiorly from the nasolabial folds to the preauricular regions and mandibular ridge; the region from the mandible to mid-neck was treated to address neck laxity.

Mild erythema developed in all patients, as it was used as a treatment endpoint. However, it was transient, lasting an average of 2.3 hours and no longer than 12 hours. Other side events encountered included mild, acute edema, and rarely, transient dysesthesia.

Follow-up assessments were made immediately post-treatment and one week and one, three, six and 12 months post-treatment.

Responses were graded using a quartile rating scale, where 0 = < 25 percent improvement, 1 = 25 to 50 percent improvement, 2 = 51 to 75 percent improvement and 3 = > 75 percent improvement.

At the three- and six-month visits, the average improvement scores were 1.6 and 1.5, respectively, for the cheeks and 1.25 and 1.3, respectively, for the neck. All patients achieved at least 25 percent improvement, while there were a few who benefited with a >75 percent change.

"There is no way to predict who will be a great responder, and while everyone in this study experienced some clinical improvement, it is possible that a patient could show no visible response.

The worst case scenario, however, is that the patients who achieve minimal to no change will be out the cost of the procedure, but at least they are not risking significant complications or post-treatment morbidity," says Dr. Alster, who is also clinical professor of dermatology, Georgetown University, Washington, D.C.

Based on the continued improvement observed during the first 3 to 6 months after the procedure, Dr. Alster hypothesized that the mechanism of action whereby the radiofrequency procedure causes tissue tightening involves not only immediate collagen contraction, but also a secondary collagen synthesis and remodeling process.

"The tissue response is not unlike what occurs after ablative laser resurfacing, although it seems to be less prolonged since the peak benefit after the radiofrequency treatments occurs by 3 to 6 months," she says.