Diprivan - not for home use!

Apparently, Diprivan has been found at the former home of the late Michael Jackson. This story is becoming more tragic by the day.

Diprivan, also known generically as propofol, is a powerful intravenous anesthestic agent. In the right hands, it is a useful drug, permitting anesthesia with a low incidence of postoperative nausea and vomiting. In the wrong hands, however, it can be dangerous.

In small doses, diprivan causes sedation. In larger doses, it can induce unconsciousness, and a state of general anesthesia. And a distinct lack of breathing, which can permanently ruin your day.

Sometimes, the same dose in one person will give a different response in another person. Or a slight increase in the dose can push the patient from mere sedation to complete unconsciousness. So, the physician administering propofol needs to know how to monitor and maintain the patient's airway - which might include intubating the patient. This is everyday stuff for a trained anesthesiologist or nurse anesthetist.

There is no way that this drug has any legitimate use outside of a controlled medical setting like the OR or ICU, and certainly no way it should be in a private residence.

U.S. Obesity is getting worse...

According to a recent report, obesity rates in the U.S. have further increased over the last year, with adult obesity rates rising in 23 states.

For the fifth year in a row, Mississippi had the highest rate of adult obesity at 32.5%. Three other states - West Virginia, Alabama and Tennessee - also had adult obesity rates in excess of 30%.
In just one state - Colorado - was the adult obesity rate below 20%.

In 1991, not one state had an adult obesity rate above 20%.

Mississippi also had the highest rate of obese and overweight children (ages 10 to 17) at 44.4%. Minnesota and Utah had the lowest rate at 23.1%.
Childhood obesity rates in the US have more than tripled since 1980.

This is an epidemic, people!

Accutane pulled off the market

A report by Bloomberg news (link) reports that the makers of Accutane, facing mounting legal costs over claims linking the drug to bowel disease, have decided to withdraw the acne drug Accutane from the market.

Generic forms of Accutane are still available.

The Lipo-laser: does it work?

We are now starting to see ads in Orlando for a new fat-melting treatment, a laser beam that melts fat after shining the beam on the the skin. Known as the "lipo-laser", or more properly, the Zerona, the manufacturer claims that its use can result in the loss of inches of fat - without surgery, injections or other invasive procedures.

The laser used in this machine, is a 635 nm wavelength diode - the very same laser that is commonly used in many hand-held battery-powered laser pointers. According to the manufacturer's website, the laser power is listed variably in different parts of the webpage, between 7.5 milliwatts and 14 milliwatts, which again is only slightly more than the typical 5 milliwatt laser pointer. (By way of comparison, most lasers used for ablative skin resurfacing treatments are in the neighborhood of 30 watts or more, or four-thousand times more powerful.) Thus, this new machine falls into the category of "low-level laser therapy".

The FDA has approved this device - in the same category as an infra-red heating lamp - according to the FDA's own 510(k) document posted on the laser manufacturer's website. N.B: it's not currently approved as a fat melter.

Neira and associates have been enthusiastically promoting the use of low level lasers to help with liposuction for several years. They claim that use of this type of laser leads to a deflation effect on the individual fat cells, resulting in the contouring effect.

This claim is certainly controversial. A study published in the Plastic and Reconstructive Surgery Journal, performed by the well-respected Plastic Surgery & laser group of Brown, Rohrich, Kenkel, Young and associates at UTSW, carefully duplicated the Neira protocol for laser fat treatment. However, they found no appreciable difference with this laser treatment, comparing the fat before and after treatment under a scanning electron microscope. Zip. Zilch. Nada. There was no effect whatsoever on the fat in the treated area, and certainly no evidence of any fat-cell deflation.

I have no personal experience with the new Zerona machine, and while I would love to have a non-invasive method to treat fat, the physics of the device make it hard to believe that the beam could possibly penetrate through the skin down to the underlying fat with enough energy to do anything.

I'll need to see better evidence from independent researchers before I can accept and recommend this treatment. To me, it seems like waving a laser pointer over the skin, and somehow expecting the fat to magically disappear. Caveat emptor.

Sunscreens: look for UV-A and UV-B protection

With the onset of ridiculously hot weather here in Orlando, it's time to talk about sunscreens. Of all the things you can do to continue having great looking skin over time, using a daily sunscreen is probably the #1 most important thing to do.

It turns out that choosing the best sunscreen is a little complicated.

While it is common knowledge that it is the ultraviolet portion of sunlight that causes sunburns, skin cancers and sun damage, most people may not realize that their sunscreen might not be blocking all the forms of ultraviolet light effectively, even if it has a high SPF number.

Let me explain. Ultraviolet light is divided into 3 main categories:
- ultraviolet A (320-400nm), which is mostly responsible for photo-aging and sun tans, but is also linked to skin cancer (UV-A)
- ultraviolet B (280-320nm), which is mostly responsible for sunburns and skin cancers (UV-B)
- ultraviolet C (<280nm), which we don't worry about too much, as it is blocked by the ozone layer

In the past, sunscreens here in the U.S. were designed to focus on protecting you from UV-B. The classic "SPF" numbers, for example, are based on how well the sunscreen blocks UV-B - but not UV-A. This helped with preventing sunburns and reducing the risk of skin cancer....but it fell short on protecting you from photo-aging, with fine wrinkles, loss of skin elasticity, and pigmentation irregularities.

We've now understand that the ideal sunscreen should give total UV protection - with both UV-A and UV-B coverage. This has been shown in clinical studies to make a huge difference in protecting the skin. The American Academy of Dermatology now recommends that the amount of protection from UV-A and UV-B be equally weighted.

How do we protect against UV-A? Well, you can either use agents which block the rays, or agents that absorb the rays. The three most commonly used ingredients for UV-A protection are:
- Titanium Oxide or Zinc Oxide (physical blocking agents)
- Parsol 1789, also known as "avobenzone"
- Mexoryl SX and XL
The latter two are chemicals that filter the UV light. Look for these in your sunscreen's ingredient list. If you don't see any of these ingredients listed, then you probably are using an older formulation, and need to get a more up-to-date product with better protection.

Mexoryl seems to be an improvement over Parsol 1789, with more efficient UV-A coverage and better photostability. Mexoryl has been available in Canada and in Europe since the early 1990's - but only was FDA approved here in the U.S. in 2006. It's available in several products, such as the Anthelios line from La Roche-Posay or the Ombrelle line from L'Oreal. These are excellent, if somewhat pricey, products. They are widely available online.

Famous sun tanning myths:

"It's a cloudy day - I don't need sunscreen."

"The SPF in my makeup/moisturizer will protect me from sun damage."

"Once I apply sunscreen, I'm good for hours."

"I can't get skin cancer/photo-damage if I just use a tanning bed."

"I need to get a good base tan before I go on vacation, so I don't burn."


Now, there are many good self-tanning products - so you can fake the sun-kissed look, without exposing yourself to the aging effects of tanning.

On-line photo morphing for plastic surgery - is it any good?

There are a few websites that claim to simulate the effects of plastic surgery on a photo that you can upload to the site. Others have adjustable 3-D renderings of models, where you can adjust their appearance by moving slider-type controls, to more closely mimic your own appearance.

I've looked at a couple of these, and yes, they are fun to play with. You can check them for yourself: lookingyourbest.com, reshapr.com, and liftmagic.com

Unfortunately, they are quite limited with what they can do, and how realistically it corresponds to what surgeons can achieve in the operating room. I found the programs worked acceptably well when modelling the effect of wrinkle smoothing ("airbrushing") lines and wrinkles. But I thought they fell short when modelling the much more complicated effects of rhinoplasty, blepharoplasty or facelift surgery. For example, the rhinoplasty simulator shows only a generic narrowing of the width of the nose on the front view, or reduction of a hump on the nose on the side view. There's no way to simulate nasal tip surgery.

The breast augmentation program at lookinyourbest.com claims to show the effect of certain size and shapes of breast implants. While this site does give potential patients some education about the difference between high profile and moderate profile implants, I felt that the results pictured did not look like what the real result would be with an implant of the stated size or shape.

So, use these websites for fun - but they are not very representative of what your post-operative appearance will look like at all.

Obesity and Pancreatic Cancer

Pancreatic cancer is the fourth leading cause of cancer-related death for both men and women in the U.S. An interesting new study, published this week in the Journal of the American Medical Association has found that, not only is obesity linked to the risk of developing this fatal disease, but that obesity in early adulthood in particular makes you significantly more likely to develop the disease, compared to gaining weight later in life.

The researchers from M.D. Anderson Cancer Center found that obese youths between the age of 14 and 19 years old had a 60 percent higher chance of developing pancreatic cancer than their less overweight peers.

Obese individuals between the age of 20 and 40 were two to three times more likely to develop pancreatic cancer. Interestingly, the risk levelled off for those who gained the weight in their 40s and 50s.

The study also found that obese or overweight individuals were more likely to develop pancreatic cancer earlier on their lives.

Since the medical and surgical treatments for cancer of the pancreas are so very limited, this data adds yet another argument to the need to combat the obesity epidemic here in the United States. Go to the gym and do your bit for cancer prevention!

Dysport - now here

Dysport - the recently approved competitor to Botox Cosmetic - is now being shipped to U.S. physicians. We have both products in our office now, and are testing Dysport, seeing how it compares to Botox, the market leader. So far, there are some subtle differences, but both seem to work well in relaxing dynamic wrinkles of the face.

It will take a little education for patients to get used to the fact that the drug doses are measured differently. Botox units are not the same as Dysport units, even though they sound similar. It's a bit like measuring someone's height in feet, compared to measuring it in yards. Same height, just different numbers. Dysport comes in a 300 unit bottle, Botox comes in a 100 unit bottle - but the clinical effect is approximately the same, as far as we can see, with a 3:1 ratio.

Dysport is priced so that it is a little less expensive than Botox (at the 3:1 conversion ratio), so patients who wish to save a little money while they are fighting their wrinkles may want to give Dysport a try.

When Bad Lips Happen to Good People

One of the hallmarks of unfortunate plastic surgery in many celebrity photos is the overdone lip augmentation. The lips in these photos generally appear overstuffed, like two tubes, or two sausages lying side by side.

The real reason that these results are bad is that the idea of creating a beautiful normal lip has gone out the window! Real lips have many subtle features in their shapes - and beautiful lips maintain these features. Unskilled practitioners just "pump in" fillers without regard for the details of the anatomy. Skilled practitioners shape and enhance the underlying forms.

For example, the upper lip and lower lip are not the same size. Usually, the lower lip is about twice the height of the upper lip. It's important to maintain this 2:1 ratio when enhancing lips. If the lips are made to be the same size, this will make the upper lip appear excessively large, which is not desirable.

Secondly, lips have subsections or segments to them. The upper lip has three segments, the lower lip has two. It's important to recognize these segments and maintain their individual shapes when performing lip enhancement with fillers. For example, since the lower lip should have two symmetric halves, with a slight depression in between - the plan for the filler treatment should be designed this way too.

The central portion of the upper lip and the adjoining skin is particularly unique, with features known as "cupid's bow" and the "philtral columns". A well done lip augmentation preserves and enhances these normal contours, rather than obliterating them through excessive filling. Plastic surgeons have a unique understanding of the anatomy of the lip, as the surgical repairs for children with congenital cleft lip problems also require the restoration of these same anatomic features with careful attention to subtle anatomic details.

In addition to enhancing the outline of the lips, adding volume to the lips is also helpful to restore a loss of lip fullness that happens with aging, or to enhance the look of lips that were naturally thin. Once again, respect for the segmental lip anatomy is key to getting a good result. So is restraint.

Excessively sized "pillow lips" will not look attractive, no matter how you do them. Sometimes patients get carried away with their desires for lip fullness... and the results may look peculiar. In these cases, a responsible physician will have to tell the patient, "No - that won't look good."

The bottom line:
1. Careful communication about the desired result with your practitioner is essential.
2. Start small / be conservative at first, using a more subtle approach.
3. Avoid long-lasting or permanent fillers, such as silicone, radiesse or artefill, in the lip. If there is an unsatisfactory result, you could be stuck with it. The options for correcting lumpy looking permanent fillers are very limited.
4. Look at lots of before and after photos when evaluating the previous results of your practitioner. Your injection specialist should have a light touch and an artistic eye. If you see some of the problems we've discussed here, go elesewhere!

Happy Father's Day!

Counterfeit Botox

As we've discussed earlier, Botox injections are the most popular cosmetic procedure overall in the U.S. But Botox is expensive - and Allergan, the manufacturer, has been steadily raising their prices each year.

This has created a black market for Botox, with counterfeit and imitation Botox knock-offs. These imitations are not FDA-approved, and vary widely in their potency, quality, and source. But they certainly are cheap....

Many of these imitators originate in China. Brand names such as BTX-A, Botutox, Estetox-A, Refinex, Novotox, Canitox, QuickStar and Linurase are commonly seen knock-offs.

A recent review of these products showed their potency varied widely: from zero potency (no effect at all) to 5 x the indicated potency (way too much).

Counterfeit Dysport is also beginning to show up as well.

Allergan has put holographic stickers on the bottle, in an effort to deter counterfeiting.

If the Botox price quoted appears unusually low, watch out for:
- over-dilution (watered-down) with fewer units of Botox per syringe,
- use of grey-market / black market Botox imitators

If the price seems "too good to be true", ask to see the official Botox hologram.

Can Botox be purchased from Canada? According to U.S. Federal regulations, physicians or corporations can not legally import large quantities of Botox (or any other medication) from anywhere, even if the Botox product was legitimately made by Allergan. Cross-border drug importation is a BIG DEAL to the FDA, who frowns on this practice. Despite this, there are some people that take the legal risk of Federal-level drug importation & trafficking prosecution, in order to save a few dollars of expense.

Caveat emptor.