The 20th Anniversary Komen San Francisco Race for the Cure!
Sunday, September 26, 2010
Along the Beautiful Embarcadero, starting and finishing by the Ferry Building.
5K Run/Walk & 1 Mile Fun Walk

Up to 75 percent of the net income from each domestic Affiliate Race stays in the local community to fund breast health education and breast cancer screening and treatment projects. So get off your bottoms and enjoy our beautiful northern california fall. Not only will it be good for breast cancer, it will benefit your heart as well.

Cost is $30.  Your kids ages 6-12 can enter as well for $10 (includes a tshirt).

Not a runner? For $35, you can join the “sleep in for a cure” and get a t shirt as well. (I love that they have this feature too.)

https://secure.info-komen.org/site/TRR/RacefortheCure/SFO_SanFranciscoAffiliate/1943285177?pg=ptype&fr_id=1813

I have been around medicine my whole life.  My father was a plastic surgeon as well.  Back in his day 30 years ago when a patient had insurance, he billed insurance for x amount, and they paid x amount.

What a concept.

When I started my practice I got on to as many insurance plans as I could.  It was a way to network with patients and grow my practice.  But I noticed the older doctors were trying to get off insurance plans.  You’ll see a lot of the great internal medicine doctors don’t take any insurance anymore- they have become “concierge” doctors.  Why?

• Because most insurance does not pay doctors well.
• They will only pay a portion of the billed amount.  I could charge $100,000 for a surgery.  But insurance plans have what is “allowed” for each CPT code.  This is the maximum I can get paid.  And it is a small number.
• This has caused doctors to need to increase volume to make a living.  Doctors don’t want to slam a gazillion patients into a day.  They have been forced to do that to make ends meet.  Particularly in Silicon Valley, rents are high. Costs of employees are high.  Don’t forget malpractice, office supplies, medical supplies, etc etc.  Most medical offices have at least one employee dedicated just to billing insurance.
• When you are a solo practicioner like I am, your reimbursement by insurance is even lower.  The large groups like Stanford and the Palo Alto clinic have better negotiating power with insurance plans to get better reimbursement.
• When I am on an insurance plan, I am not allowed to balance bill the patient.  Let’s say I do a long breast cancer reconstruction case.   Bilateral.  As a surgeon, my surgery code with insurance includes ALL of your visits pertaining to that surgery for 3 months.  My visit to the hospital for the next day or two after surgery.  All of your follow ups in my office.  When I do a tissue expander I see you every 2-3 weeks.  I use supplies: saline, syringes, needles, local anesthetic.  I am not allowed to bill for any of those costs.
• You have to submit, and frequently resubmit claims to get paid.

You can still go to any doctor you want if you are on a PPO plan.  Even if they are not “on” your plan, they will be covered, though usually at a lower percentage.  We are considered “out of network.”

I know you pay high monthly fees and deductibles and copays for your health insurance.  We must for our family.  But insurance is not passing that money on to the doctors.  Most general surgeons make about $400-500 for a hernia repair.  I just did a bilateral breast cancer reconstruction case.  I saw her for a preop for an hour. The surgery took about four hours with mastectomies.  I saw her multiple times in the hospital.  Then I saw her in clinic to expand her every 2-3 weeks, for a total of 8 post op visits I can’t bill for.  My supplies were not reimbursed.  I was paid $700.  For my skin cancer excisions, I am paid almost the costs of the sutures and supplies I use.  My ER call visits I frequently don’t get paid at all.  It is pro bono work. 

All doctors pay to go to medical school, which takes four years after college.  All residencies are a minimum of three years.  All surgery residencies are a minimum of five years.  Plastic surgery is an additional fellowship, so we train even longer.  We give up the decade of our 20s to living in a hospital to learn our craft.   I trained in the days of 100+  hour work weeks, living in the hospital.  We delayed our lives- marriage, buying a home, kids.

It is tragic to see what is happening.  Older seasoned doctors retire early, when they are at the height of their career, due to poor reimbursement.  Doctors do things out of their specialty, to try to get into the cash pay areas. 

Please see the link under.  This is a group of general surgeons discussing hernia insurance reimbursement.  http://www.generalsurgerynews.com/index.asp?section_id=67&show=dept&issue_id=109&article_id=4089

So why do we not take insurance plans?  Because we can’t if we are to survive with a shred of our ideals intact.  I need to pay my overhead.  I don’t want to become a patient mill.  I want to give my patients the “concierge” medicine they deserve.  Surgery is a scary thing, particularly when recently diagnosed with cancer.  These patients should not be rushed.

Anatomic implants have been talked about a lot recently at our meetings.  The style 410 gummy bear implant is not available in the US.  Even when it does become available (which I have stopped holding my breath for… it is now 3 years and counting), I don’t know it will be the workhorse of breast augmentation.

Why do I like round implants? For a multitude of reasons: I get a great shape; round implants move (which I feel makes them look and feel more natural); I saw a lot of issues with the textured shaped implants during my residency (shaped implants were all the rage in the mid 90s) with wrinkles and fold failure causing leakage; and a MRI study showed when placed behind the muscle there is little to no shape advantage of the shaped implant versus round implant. 

The last issue? Rotation.

A study came out in July issue of PRS about the style 510 (the next generation after the 410) and the investigators found an 8% malrotation rate.  As they say, “anatomic prostheses are asymmetrically shaped, which can lead to a severe deformity of the breast profile when rotation around one of the axes occurs.”  In English, that means when a shaped implant rotates, it doesn’t look pretty.

Theories about why malposition occurs?

• The implant surface (more texturing is better),
• the pocket.  (type of pocket? width?),
• the tissue (thin skin can stretch out the pocket and allow lateral migration and then rotation),
• excessive movement, particularly when healing
• no friction (caused by fluid or double capsule)
• capsular contracture. 

Some of the issues may be surgery related.  You can’t overdissect the lateral pocket, and want a pocket to be taller than it is wide.  Large implants, particularly in thin patients with poor cover, rotate more.

Bottom line: Anatomic implants have issues.  This study was done in the Netherlands.  Europeans have access to the style 410 gummy bear and have used it for years.  Plastic surgeons fall on both sides of the fence when it comes to shaped versus round implants.  My mentor for my breast fellowship really likes the 410, but he as an investigator is one of the only guys who can use them, and his practice is almost all difficult revisions of prior breast augmentations, where he is making neopockets, using dermal matrix products, and using shaped implants.  Before restrictions occurred, some of my colleagues doing uncomplicated first time breast augmentation patients were able to use the 410.  Many of these colleagues didn’t like them and went back to using round implants.  So you will find much controversy on this subject. 

I think, as with all things plastic surgical, you will find the anatomic implant is the “right” choice for a certain patient population.  But which patients are those patients? I don’t know yet.  Perhaps rib cage shape? migration issues? no tissue cover? capsular contracture issues? breast cancer?  Regardless, until the 410 is available in the US, I will stick with my current recommendations.  I get great results with the round smooth gels. And the result, your happiness with a pretty breast, is what matters.

Tissue expander and implant reconstruction is the most common reconstruction done.  A big issue, particularly for my ultra thin Bay Area women, is poor coverage over the implant.  These women are thin: they have no fat, thin skin, and no breast tissue after mastectomy.  Many won’t expand well in the lower portion of the breast, which is where we’d love to see you expand more to get a natural breast look.

Along came acellular dermal matrix.  What is that in English?  It is dermis, essentially an extra layer of skin.  It is great to help “thicken” tissue which is too thin, help implant position, and give better coverage over the implant.  It has become more popular in the past few years, and has helped some patients avoid a larger surgery involving muscle flaps.

Is it better?

A recent study came out in PRS (our big plastic surgery journal) in Feb 2010 looking at 415 immediate breast reconstructions.  They compared those which used the acellular dermal matrix versus those which did not.  The study wished to assess the “risk of postoperative complications associated with the use of acellular dermal matrix assisted implant based reconstruction.” The two patient groups were matched for age, cormorbidities, smoking, radiation, cancer stage.

Findings?

Acellular dermal matrix was statistically significant risk factor for developing postoperative seroma and for infection.  There was a 4x seroma rate, and 5 x the infection rate.

There are many variables, as with all things.  This study should be taken with a grain of salt.  But I think their final thought is a good one:  “The selection criteria for acellular dermal matrix utilization in breast reconstruction should be more carefully determined by critically assessing the potential benefits.”  “Routine use of acellular dermal matrix in every implant based breast reconstruction seems unwarranted.”

I agree.

A new study in the May 1, 2010 issue of the International Journal of Cancer says implants may hinder the early detection of breast malignancies, but they do not affect patient survival.

This sounds like a lightening rod in the world of breast implants.  What did they find?

The study analyzed 24,000+ women who had breast augmentation in Canada between 1974 and 1989.  Cancers and mortality were looked at through 1997.

Breast cancer was found in 182 patients of the implant group and 202 in the control group.

• Implants delayed the diagnosis in augmented patients
• No statistical differences were seen in age at diagnosis, tumor size, histology type.
• The delay in diagnosis did not affect overall prognosis.
• Breast cancer survival was similar in both groups.

What does this mean?

I have not been able to read the whole article.  Due to the timing of the original breast augmentations, I suspect most of these women had first or second generation noncoehsive gel implants in front of the muscle.  Many likely had capsular contracture.  I don’t know in Canada what the breast cancer screening process is, when it is done, when it starts, how often it is done, if they use techniques like Ecklund, etc.

What I do believe:

• There is some impairment of mammograms when you put in breast implants.
• The impairment is significantly less when you go under the muscle (which is one of the big reasons I prefer submuscular.  One study quotes 39% impairment in front of the muscle vs. 9% behind the muscle relative to nonaugmented women.)
• Hard breasts / capsular contracture makes it more difficult to view the breast tissue (another reason to go submuscular, as the capsular contracture rates are lower behind the muscle)
• If you use the Ecklund technique and take more films (two additional CC and MLO views, with a fifth lateral view if needed), and use other modalities (such as ultrasound if needed) you can further reduce the risk.
• If you have implants, you should go to a mammogram center which does these techniques and is well versed in evaluating women with implants.
• Ecklund and others (published in radiology journals in the late 80s) argued implants help thin the overlying glandular breast tissue and give you a smooth backdrop, thereby enhancing the physical breast exam.

So I will tell you what I tell all my patients.  Breast implants will reduce your ability to visualize the breast.  This reduction is lower when behind the muscle.  If you have a strong family history of breast cancer, you need to strongly consider this risk.  If doing gel implants where the risk of capsular contracture is higher, particularly if you have a strong family history of breast cancer, consider a preoperative MRI so you can see your baseline prior to augmentation.  Anyone over the age of 35 should get a good baseline mammogram prior to any breast surgery.  And don’t forget your self exams (or ask a spouse/friend).  Just don’t forget.

I just found out today she lost her battle with breast cancer.   I went to her 50th birthday party last year.  Yes, 50th. I want to cry.  She was one of those women who brightened the room when she came in.  Even in the face of recurrence and brain mets and chemotherapies, she still had that beautiful energy.  Like sunshine packaged into a person.

I am so sad.   She had her first tumor when she was in her early40s.  She has a strong family history, so she was aggressive in treatment.  Bilateral mastectomies, oophorectomy, chemo, radiation.  She fought this disease like no one I have seen.  And if positive thinking and the mind can change the effects of cancer, she would have done it.

But it had reached lymph nodes.

Later it recurred.

Nadia’s Gift to me ?  Her friendship.  Her inspiration.  I am proud to have had her in my life for the time I did.  In all of the ick of fighting this horrible disease, she made her 50th birthday a blow out bash and fundraiser.  She started an organization to fight breast cancer, particularly the aggressive horrible kind affecting young women.

We forget every day is a gift.  Thank you for reminding me once again what is important.

The world has lost a ray of sunshine today.

http://www.nadiasgift.org/

Although the tumor was quite small at that time, Nadia knew it would have significant impact on her life and the lives of those close to her as she lost her mother at age 50 and two of her aunts to breast cancer. Through genetic testing, Nadia’s pre-disposition to this disease was confirmed, which presented very high odds of this life altering event and it’s ensuing re-occurrence. Attacking the disease as aggressively as she could, Nadia spent 6 hours on an operating table as a double mastectomy and prophylactic oophorectomy were performed. This was followed by many weeks of chemotherapy and radiation. However, she also learned of lymph node involvement in the process, which became the pathway for future metastasis that she continues to fight every day. Over the course of time, Nadia has had brain surgery to remove a mass on her cerebellum and two procedures of radio surgery to contain other brain lesions determined to be inoperable. She’s had numerous direct spinal infusions of chemo to address tumors that developed there. These infusions became ineffective over time, which led to an intensive daily course of whole brain and spine radiation for six straight weeks in the fall of 07. Since that time Nadia has endured continued chemotherapy to manage a metastasis in her liver and a reoccurrence in her brain. Now partially disabled from the brain and spine involvement and the treatments themselves, through all of this, she’s never really flinched. She’s never lost her incredible smile, never lost her ability to so readily laugh with, and love her family and many close friends. Or how she finds a way to bring her husband joy every day.

They are good for you.  Is more better? What happens when you take more? Do you pee it out? Or does it help you heal better?

When looking into this, I went to the scientific articles, not the press.  I do take things with a grain of salt: all scientific papers are not equal.  Was it a good study with adequate numbers and controls? etc etc.

So. What did I find?

Wounds are harder to heal for some people:

• Age
• Steroids
• Radiation
• Chemotherapy
• Diabetes
• Smoking
• Poor nutrition

As a surgeon, I see the effect of poor blood flow causing wound  healing issues.  Diabetes, smoking, high cholesterol, exposure to cold.  These are not important for small cuts.  But when we do “flap” surgeries like breast lifts, facelifts, and tummy tucks, blood supply is critical.

One good study I saw stated the most important factor was not a vitamin level, but your protein level.  They found if your serum protein was less than 6g/dl, you would not heal well.  They did not see a correlation with Vitamin C, Vitamin E, or anemia. (I was suprised by the anemia part- you need blood to bring the oxygen and nutrients to the wound to heal.)

Vitamin A:

Vitamin A stimulates the early inflammatory resonse to healing (which is good- it’s like the paramedics have arrived).  A deficiency causes impaired collagen synthesis.  In normal people, taking extra Vitamin A likely does little.  The place Vitamin A is well documented to help is in those on steroids.  Steroids, like Vitamin E, inhibit healing.  They measure this by looking at the tensile strength of the wound, ie how easy is it to break open?

A normal dose is 2000-3000 IU/day. When trying to do a supplement to help with healing, the dose is 25000 units.  This should be done for a short period of time 1-2 weeks.  High doses of Vitamin A are not good if trying to have a child, or if you have a history of liver disease.

Vitamin C:

We all know about those scurvy pirates AAARRRH.

One of the original papers I found supporting Vitamin C and wound healing was a 1937 paper, so this is not news.  Vitamin C is needed to make collagen.  It is also an antioxidant and thought to strengthen the connective tissue in skin, muscle, and blood vessels.  When you don’t have Vitamin C, you get scurvy.  Scurvy presents with skin lesions and bleeding from mucous membranes.  People look pale, can lose their teeth, and are depressed.  We humans lack long term storage for Vitamin C.

What dose? Normal daily recommendation is 60 mg/day.  If you lack Vitamin C, they can recommend up to 1-2 grams a day.  A typical wound healing dose though is likely around 500mg.

Vitamin E:

Aaaaah.  This is such a tricky one.  Vitamin E is a strong antioxidant and helps your macrophages work (fighters who eat up bacteria and invaders and call in more troops to fight infection).

BUT I make all my patients stop Vitamin E before surgery.  Why?  1.  Because it makes you bleed.  The normal amount in your multivitamin is okay.  The 400 IU is not.  2.  At higher doses  it can inhibit collagen synthesis and decrease tensile strength of wounds, just like being on steroids.

I get a lot of push back on vitamin E.  “I hear it makes scars better.”  It weakens scars.  The only scars it “makes better” are those which are hypertrophic or keloid.  For a normal scar, you don’t want to weaken it.  It has just the right amount of scar and strength.  If you weaken a normal scar, it will indent or widen.  So for “good healing” I don’t recommend more than what is in a typical multivitamin.

SO to sum it all up, for normal patients you likely don’t need any supplements.  You will heal just fine.  If you have any issues on the list of healing issues, then consider supplements (after you clear it with your doctor of course).

Yes, Protein.  Yes, Vitamin A. Yes, Vitamin C.

No Vitamin E.