Fake Plastic Surgeons

There has been a media frenzy during the last month, related to the topic of "fake" plastic surgeons. Recent newspaper articles (The Star, 16 Nov 2009 - Read Here) have highlighted some of these unfortunate incidents. During my discussions with patients, friends and colleagues, it has become apparent that, in general, the public are unaware of who may call themselves a Plastic Surgeon and who may perform cosmetic surgery procedures. This post will answer some of those questions.

Who may call themselves a Plastic Surgeon?
In many countries, any qualified doctor may call themselves a plastic surgeon. However, in South Africa, only medical practitioners who have been registered with the Health Profressions Council of South Africa (HPCSA) for independent practice as a Plastic and Reconstructive Surgeon may use this title. As the HPCSA is a statutory body, it is illegal for any other practitioner to use this title. The HPCSA will only register a doctor (and provide them with the necessary certificate) as a Plastic Surgeon once the doctor has provided the following documentation:

• Proof of completion of a minimum of 4 years of approved specialist training in an academic unit. This is provided by annual renewal of the doctor's "W-number" (a unique, registered and approved training post number).
• An original signed letter from the head of the academic unit stating that the doctor has duly completed their training to the satisfaction of the department.
• Proof of independent examination of the doctor, in all aspects of plastic surgery, at the completion of their training (exit examination). The HPCSA currently accepts 2 forms of examination : The national College of Medicine of South Africa (CMSA) fellowship examination in Plastic and Reconstructive Surgery, or the Master of Medicine in Plastic Surgery degree awarded by an approved university.

An official certificate from the HPCSA provides proof of registration.


How can you tell if your surgeon is registered?
A copy of the above HPCSA certificate can be requested from the doctor. In addition, all medical professionals require a "practice number" (PCNS) which is obtained from the Board of Healthcare Funders of Southern Africa (BHF). Each practice number is unique and has (in the long format) a 3 digit code at the start which identifies the area of practice of that doctor. For instance, 010 is the identifier for specialist anaesthetists, 014 for general practitioners and 036 for plastic surgeons. All medical aid companies have access to this data.

Who can perform cosmetic surgery?
In the past cosmetic surgery was performed by many doctors, some of whom were not plastic surgeons. The Medical Protection Society (MPS), which provides doctors with professional insurance, differentiated between trained plastic surgeons (as above) and other practitioners with regard to the fees payable. The practitioners undertaking cosmetic surgery without the formal training described above were required to pay an annual fee 5 times higher than trained plastic surgeons. This is a direct reflection of the actuarial risk of complications in untrained hands. Currently MPS no longer covers these practitioners if they perform cosmetic surgery as the risk is now deemed unacceptable. This should alert the public to the risks involved in consulting untrained surgeons.

In addition, the HPCSA has released a statement on who may perform cosmetic surgery (13 Oct 2009). The statement follows here (italics) :

COSMETIC PROCEDURES
a. “Cosmetic Surgery” be defined as an operative procedure in which the principal purpose is to
improve the appearance, usually with the connotation that the improvement sought is beyond
the normal appearance, and its acceptable variations, for the age and the ethnic origin of the
patient – Steadman’s Dictionary for Health Professions and Nursing File, 2004;
b. cosmetic surgery was always an elective procedure;
c. cosmetic surgery was performed in the main by specialists in plastic and reconstructive
surgery, but may also be performed by other specialists which have formal structured
training, assessment and ongoing professional development in certain aspects of
cosmetic surgery relevant to those particular specialties;
d. assessment of competence of any such registered specialist in any particular cosmetic
surgical procedure which has not formed part of specialist training shall be by a
training/examination body accredited by the Board for such training;
e. reconstructive surgery shall not be deemed to be synonymous with cosmetic surgery;
f. cosmetic medicine was the field that dealt with any non-surgical cosmetic procedures;
g. cosmetic medicine was not confined to any specialty or discipline;
h. registered practitioners should always act within the Medicine Control Council
recommendations and in accordance with Rule 19 of the generic ethical rules of the HPCSA
as appended:
“19. A practitioner shall in the conduct and scope of his or her practice, use only –
(a) a form of treatment, apparatus or health technology which is not secret and
which is not claimed to be secret; and
(b) an apparatus or health technology which proves upon investigation to be
capable of fulfilling the claims made in regard to it”
i. any practitioner performing cosmetic medicine procedures which result in permanent
anatomical and/or physiological changes shall be appropriately trained as for cosmetic
surgery.

How are Plastic Surgeons Trained?
There have been a numerous letters and comments regarding the newspaper articles described above. I feel that it is important to describe the training that a doctor must undergo to become a registered plastic surgeon. Here is the process :

• Undergraduate medical degrees take 6 years to complete. After completion of the undergraduate training, the title Dr may be used, but the doctor may not undertake independent practice.
• A period of internship must be completed (previously 1 year, now 2 years)
• A period of community service must be completed (previously 1 year, now 2 years)
• A period of medical officer training in specialist surgical disciples must be completed (usually 1 year)
• Specialist surgical training in general surgery is required, completing at least 2 years (but often more)
• Specialist plastic surgery training for a minimum of 4 years is required.

This means that the "fastest" possible route was previously 15 years of training, but is currently 17 years.

During the specialist training period both academic knowledge and surgical skills are required. This is true for all aspects of reconstructive surgery, as well as for cosmetic surgery, which forms an integral part of our training. The skills required for cosmetic surgery are composite skills and can NOT be obtained in isolation, but are built on the foundations of other skills obtained in general surgery and reconstructive surgery. It is naive to believe that general practitioners, who have not undertaken this rigorous basic training can obtain comparable skill levels.

With regard to the academic knowledge that is required for the safe practice of plastic surgery, many people assume that this is less than other specialists. Each discipline has a "standard" text book - Plastic Surgery, 2nd Ed, 2006, ISBN0-7216-8811-X is ours. This is the largest medical text every published (on any medical subject). In addition to the largest medical text, numerous articles and specialized texts are also required to build the knowledge base that is essential to the practice of plastic surgery. Clearly, it is impossible to duplicate such experience outside a formal training program.

I hope that this post will enlighten not only the public, but also our medical colleagues, on the personal and professional efforts that must be may to become a plastic surgeon and why we guard our title so fastidiously.

Best Regards

Marshall

Dysplastic Nevi - "Funny looking Moles"

Many patients present to a plastic surgeon’s office concerned about a “mole”. The most important diagnostic exclusion is that of melanoma. With regard to this, the diagnosis of a “mole” as a dysplastic nevus (pl. nevi) is important.

What is a dysplastic nevus ?

A dysplastic nevus is defined as a pigmented area, (a “mole”) with clinical and histological features of concern and which may be associated with an increased risk of melanoma.

What does it look like ?

Dysplastic nevi are pigmented, ranging from light brown to very dark. They are usually flat around the edges with a raised central area and are described as having a fried-egg appearance. They are usually more than 5mm in greatest diameter and have irregular, fuzzy edges.

  

The photo above is a bopisy proven dysplastic nevus and the picture below shows a fried egg to emphasize the occasional central papule

Where do they occur ?

Dysplastic nevi occur in up to 10% of the population. Patients may be born with them, but they usually increase in number during puberty. New nevi may also occur in adult life. They can occur anywhere on the body (even on the breasts or buttocks which are usually covered with 2 layers of clothing), although they usually occur on the intermittently sun-exposed areas such as the back. They may be “dysplastic” at their first appearance or they may develop more atypical features with time, especially in “moles” with a “junctional component”.

Above is a schematic diagram of normal skin and below shows how the melanocytes are present below and above the dermo-epidermal junction - so called "junctional nevi"

What is the risk attached to a dysplastic nevus ?

Dysplastic nevi are associated with an increased risk of melanoma – 15 times higher than patients without them. If a patient has dysplastic nevi AND has had a melanoma before, the risk of another melanoma is 100 times higher than the normal. If a patient with a dysplastic nevus has had a melanoma before, and has a first degree relative with a melanoma, their risk of another melanoma rises to 1500 times more than the normal.

Melanoma arises within a dysplastic nevus in about 50% of cases (44-80% in different studies). This means that the other 50% of melanomas come from otherwise normal looking skin. Each dysplastic nevus however, has only a 1 in 10 000 case of becoming a melanoma – a very low risk.

What to do about them?

Having dysplastic nevi is a melanoma risk, but each nevus is actually low risk.

This means that simply cutting them out will only reduce the risk for that patient very marginally. Most international guidelines do not support prophylactic excisions.

Self-examination is cheap and non-invasive and is often recommended despite the lack of scientific evidence.

Genetic screening for CDKN2A mutations is a promising avenue to screen at risk patients, but correlation with melanoma risk is not perfect and it is expensive and is thus not recommended except in the context of clinical trials.

Ocular examination (examination of the retina, done by an ophthalmologist) has been associated with an earlier detection of melanoma of the retina and annual screening in at risk patients is recommended.

The most important screening tool is digital epiluminescent microscopy (mole-max or mole mapping) done by a dermatologist. It gives a much clearer view than can be achieved with the naked eye and stores the digital image for future reference. “Moles” that are suspicious are then referred to the plastic surgeon for excision. This method improves the diagnostic yield and limits unnecessary surgery, while providing the optimal risk management for these patients.

 These two photos show the MoleMax machine and a screen shot from the device

Sunscreen use has been associated with lower numbers dysplastic nevi and should form part of the risk management strategy for patients.

My Personal Recommendation :

1. All patients should perform monthly self-examination of their “moles”.

2. All patients should wear sunblock with SPF 30 or greater every day. Additional clothing cover should be used whenever possible.

3. At risk patients should be screened with a mole-max scan annually. Any suspicious moles should then be excised.

4. An ocular examination should be done every 2 years, except in higher risk patients, when it should be done annually.

5. If a particular “mole” bothers the patient, then I remove it.

Best Regards

Marshall

Can Botox be used in the management of Parkinson’s disease ?

This interesting question was recently posed by a patient. While it may seem counter-intuitive, the short answer is, YES  !

But first, a little bit about Parkinson’s disease. The basic problem is a progressive loss of neurons in deep brain area. These neurons (mainly) produce the transmitter dopamine. The end result is an abnormally increased activity certain parts of the brain, which causes the characteristic motor problems. Other problems may include depression, memory and concentration problems, and behavioral problems. Another neglected facet of the disease is malfunction of the autonomic nervous system, termed dysautonomia.

The symptoms that are manageable with Botox include the following:
Drooling
Blepharospasm - spasm of the eyelid muscles causing a permanent wink ;-)
Constipation (due to spasm of the anal sphincter muscle)
Dystonic rigidity. This often troubles younger patients. Neck, hand and foot muscles go into spasm which is often painful. Classically, the foot goes into inversion with curling of the toes.

Drooling

While there are surgical operations to reduce drooling as well as certain medications, Botox is very effective and minimally invasive. Between 5 and 15 units (usually 10) is given into each parotid gland via 1-3 injection sites. Care should be taken to inject just within the gland capsule and not too deeply or paralysis of the muscle which help with chewing will be affected (unless of course these muscles are in spasm and the teeth grind inappropriately – termed bruxism). It is prudent to wait about a month and assess the result before giving more botox. Additionally, 5 units may be given into each submandibular gland. Good effects are noted for about 4-6 months.

Blepharospasm

The permanent wink is not cute. It may be very distressing and cause loss of visual field in the affected eye. Very small doses of botox, 1-2 units should be given just subdermally to affect the obicularis occuli muscle. It is very important to not overdo the Botox, since ectropion (drooping eyelid) may occur, especially in older patients.

Constipation

Partial paralysis of the anal sphincter is often achieved by multiple injections of more diluted Botox (100 units in 10ml). 20 to 60 units are used at the discretion of the physician (usually a gastroenterologist). Again, it is better to be more conservative than have incontinence.

Dystonic Rigidity

There are different types of rigidity and it is the patients with the “lead pipe” type (as opposed to the “cog-wheel” type) who benefit from Botox injections. The aim is to partially paralyse the affected muscles to relieve the spasm. Although the limb is weakened it is actually more functional, as the balance is improved. As it is critical to get this balance right, where smaller muscles are involved, EMG (electromyelogram) localization done in conjunction with a neurologist is often useful to pin-point the problematic muscles.

Other Uses

Some Parkinson’s patients are unable to swallow properly (termed dysphagia) and some have excessive sweating due to the dysautonomia (see above). As with constipation, diluted Botox is injected under direct visualization with a gastroscope into the pharyngeal constrictors. The use of Botox to control excessive sweating is well known, however this requires multiple sub-dermal injections and between 100 and 200 units are used depending on the area to be treated. About 50 units should control one armpit.

So, in conclusion, there are many surprising uses for Botox in Parkinson’s patient.

Best Regards

Marshall

How Does Botox Work ?

What is Botox ? How does it work ? Will it make me gorgeous ? These are some of the questions that I am regularly asked. Below are some answers to the first 2 questions, as for the last one, well....

Botox is the crystalline form of the type A exotoxin of the bacteria Clostidium botulinum. It is this toxin that is responsible for the previously fatal disease botulism. The word is derived from the latin word botulus, which means sausage - since a particlarly nasty outbreak occured in Stuttgart as a result of tainted sausages!

It is purified from the Hall strain of the bacteria and amazingly all Botox sold throughout the world since 1997 comes from the same batch (BCB2024). Botox is the most potent biological neurotoxin known (one gram could kill every occupant in a major city) and so incredibly small doses are used for medical purposes.

Botox is sold in vials of 50 or 100 units. More correctly, it is sold in "mouse units". One mouse unit is the amount of Botox required to kill at least 50% of a group of 18-22 gram mice when injected to their abdomens. This is bad news for mice with wrinkles, but luckily these results can be extrapolated to human weights so that about 3000 units would be a similarly fatal dose. All cosmetic doses are nowhere near that figure and Botox is thus quite safe.

Botox works by preventing the release of the neurotransmitter from the end of a nerve to the muscle it innervates. It effectively "gags" the nerve to prevent the message from getting through. This effect lasts for several months (depending on the type of nerve).

Botox only works works on nerves which use the transmitter substance acetyl-choline (ACh) such as the nerves which control muscles and sweat glands. It does not affect sensory nerves. Well, that is not true. There are receptors in the sensory nerve endings which are also affected by Botox, but their specific purpose is not known. Normal sensation remains intact. It may be that the ability of Botox to relieve chronic migraines is related to these receptors.

When used correctly, partial or complete paralysis of the target muscle occurs. In the face, this has two consequences. Firstly, there is a decline (or absence) of muscle activity. This causes the appearance of wrinkles to diminish. Secondly, the facial muscles do not work singularly - they work in coordinated groups (unlike politicians). Weakening one member results in altered vectors. This is often unappreciated by inexperienced practitioners and may result in some pretty weird looking facial features. Jack Nicholson was born that way, most other people got Botox to look like that!

When properly executed and maintained, very pleasing results (and thus very pleased patients) are the norm. So in answer to the last question...

Best Regards

Marshall