Recently the news has been flooded with headlines on the misuse and over-prescription of opioids. President Obama has announced efforts to provide more financial support and treatment to Americans suffering from opioid and heroin abuse.1 The Centers for Disease Control and Prevention has released new guidelines on prescribing opioids for chronic pain, which recommend non-opioid therapy as a preferred form of treatment,2 and a growing number of local governments across the nation are taking action to help curb this issue in their own backyards.
As a plastic surgeon who has been practicing in the Los Angeles area for 22 years, I've seen how readily opioids are given after surgery—both in the hospital and in the surgeon's office. I am acutely aware of how relying too heavily on them can unintentionally put patients on a path toward misuse, abuse, and addiction. Research shows that more than 70 million patients receive opioids after surgery each year, and one in 15 will go on to long-term use.3,4 Statistics are one thing, but hearing of a patient who became addicted to opiods after a breast reduction hit home for me.
Surgeons prescribe postoperative opiods and we need to be leaders in changing what has become a dangerous routine. Fortunately, there is an option—multimodal therapy—which aims to control pain using a combination of non-opioid medications including regional anesthesia, anti-inflammatories, and a long-acting local analgesic (liposomal bupivacaine). Multimodal therapy can offer prolonged pain control and reduces, or in some cases eliminates, opioid use after surgery. In my experience, utilization of this strategy has yielded a measurable decrease in patients' need for opioids. I have also seen a considerable increase in patient satisfaction and comfort thanks to reduced opioid-related adverse effects such as nausea and constipation.
THE OPIOID EPIDEMICS BY THE NUMBERS
Deaths from prescription opioids— drugs like oxycodone, hydrocodone, and methadone—have quadrupled since 1999.
More than 40 Americans die every day from prescription opioid overdose.
At least half of all opioid overdose deaths involve a prescription opioid.
Source: Federal Centers for Disease Control and Prevention
So why hasn't the multimodal therapy taken off? In part this is due to a lack of education across the spectrum—from patient to physician to pharmacist to administrator—on effective non-opioid alternatives. In some cases it's also the result of failure to look beyond point-of-sale product costs at the impact these treatments have on the total cost of care. Opiods, by themselves, are inexpensive so on a direct comparison with the components of the multimodal approach (for example IV Tylenol or a long acting local analgesic) they may appear to be a bargain. However, when the whole postoperative course is looked at—from the recovery room to discharge and beyond—the cost of multimodal therapy is significantly less. And this does not even look at the cost of avoiding even one case of opiod abuse.
The war against prescription drug abuse must be waged on many fronts, and reducing or even eliminating opioid use after surgery is a battle that can be won. We have the tools necessary to make this change today. And we should. Our patients are counting on it.
3. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, et al. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425-30.
4. Carroll I, Barelka P, Wang CK, Wang BM, Gillespie MJ, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2012;115(3):694-702.
PicoSure Delivery System Cleared for Tattoos and Pigmented Lesions
The FDA granted clearance to Cynosure to market a new laser delivery system for PicoSure. Together with the FDA cleared 532nm and 755nm wavelengths, the new 1064nm Laser Delivery System improves the multi-wavelength laser technology for removing the full color spectrum of tattoo inks in fewer treatments.
The new 1064nm wavelength is designed for removal of black and other dark tattoo inks. Engineered to complement the highly versatile 755nm wavelength and the company's proprietary FOCUS Lens Array, the 1064nm and 532nm laser delivery systems enhance PicoSure's ability to remove tattoos and treat a range of dermatologic conditions including wrinkles, acne scars, and pigmented lesions.
The 1064nm wavelength will be offered as an upgrade to existing PicoSure customers. Initial shipments of the new Laser Delivery System are expected in the second half of 2016.
FDA Approves Juvéderm Volbella XC for Use in Lips and Perioral Rhytids
Allergan plc, has received FDA approval to market Juvéderm Volbella XC for use in the lips for lip augmentation and for correction of perioral rhytids in adults over the age of 21. Juvéderm Volbella XC will be available to patients in October 2016.
Juvéderm Volbella XC is formulated with Vycross, a proprietary filler technology from Allergan. Vycross blends different molecular weights of hyaluronic acid which contributes to the gel's duration. In addition, Juvéderm Volbella XC has been customized with a lower HA concentration (15mg/mL), while still providing the long-lasting results healthcare providers expect from the Juvéderm collection of fillers. This makes Juvéderm Volbella XC a soft, smooth gel appropriate for adding subtle volume to the lips and softening the appearance of perioral lines.
The safety and effectiveness of Juvéderm Volbella XC has been demonstrated in several clinical trials including the US pivotal study where 168 subjects were treated with Juvéderm Volbella XC. A 5-point scale was used to evaluate the effectiveness of the product for lip fullness and a 4-point scale to evaluate the effectiveness of the product for smoothing lines around the mouth. Approximately two-thirds of subjects treated with Volbella XC showed improvement in lip fullness and perioral lines through one year. The safety of Juvéderm Volbella XC was observed to be similar to that of the control. The most common side effects were temporary responses at the treatment site such as swelling, tenderness, bruising, firmness lumps/bumps, rednesss, pain, discoloration, and itching. Most of these side effects resolved within 30 days.
“Juvederm Volbella joins Juvederm Voluma as the second member of the Vycross family of hyaluronic acid fillers to be approved by the US FDA,” says Hema Sundaram, MD, a dermatologist with offices in Fairfax, VA and Rockville, MD. “Volbella has been available in Europe and other parts of the world for a number of years. It is suited to treatments that require softer filler products, such as fine lines and lip enhancement [and] it can be layered over Voluma in areas where it is appropriate to combine deep and superficial volumizing.”
A recent Global Aesthetics Consensus publication in Plastic & Reconstructive Surgery contains guidelines for combining HA fillers in this way, using Volbella and Voluma as a paradigm, and also for combining them with botulinum toxin, Dr. Sundaram says. “It links the scientific engineering of these products to how they behave clinically, based on new studies and the long term, international experience of the consensus group members.”
Joe Niamtu, III, DMD, FAAC, Cosmetic Facial Surgery in Midlothian, VA, says the latest filler approval is in line in with what is happening in the advancement of filler science and rheology. “Initially the goal of a filler was to have a biocompatible material that felt normal and had respectable longevity,” he says. “The simultaneous advancement of filler science and the huge demand for them has brought an increased level of customization and specificity for both injectors and patients.”
Various advancements in cross-linking filler composition have produced “thicker and thinner” fillers that lost longer. “Whereas more robust fillers such as Voluma and Lyft are intended for more lifting and deeper injections, the newer Volbella (similar to Restylane Silk) is intended for more superficial dermal injection in the case of vertical lip rhytids, but can also be used for traditional lip filling,” he says. “The addition of these new players is a boon for experienced injectors who have the skills to fine tune filler treatments. They may add confusion for novice injectors that can be overwhelmed by too many choices. The same thing can apply to patients, who can also be confused by the growing number of available fillers.”
Botox May Blur More Than Wrinkles
Botulinum toxin injections may undermine the ability to understand the facial expressions of other people, a new study published in the journal Toxicon suggests.
“The thankfully temporary paralysis of facial muscles that this toxin causes impairs our ability to capture the meaning of other people's facial expressions,” explains study author Jenny Baumeister, PhD, research scientist at the International School for Advanced Studies (SISSA) in Trieste, Italy.
It's all about embodiment or the idea that processing of emotional information, such as facial expressions, in part involves reproducing the same emotions on our own bodies. When we observe a smile, our face too tends to smile (often in an imperceptible and automatic fashion) as we try to make sense of that expression. If our facial muscles are paralyzed, the process of understanding someone else's emotion expression may turn out to be more difficult, the study authors explain.
Dr. Baumeister had a sample of subjects carry out a series of different tests assessing their understanding of emotions, immediately before and two weeks after they had had a Botox-based aesthetic procedure, and compared the measurement with a similar sample of subjects that had no treatment. Regardless of the types of measurement (judgment or reaction times), the effect of the paralysis was obvious.
“The negative effect is very clear when the expressions observed are subtle. Instead when the smile is wide and overt, the subjects were still able to recognize it, even if they've had the treatment,” explains study author Francesco Foroni, PhD. “For ‘equivocal' stimuli that are more difficult to pick up, the effect of the paralysis was very strong.”
Steven Dayan, MD, FACS, a Chicago facial plastic surgeon and author of “Subliminally Exposed: Shocking truths about your hidden desires in mating, dating and communicating,” says that it is critical for doctors to understand some of the psychological effects of botulinum toxin injections. “We might be negatively impacting people if we put too much in … in the wrong places … but just the right amount in the right places can improve a first impression, self esteem and quality of life,” says Dr. Dayan, co-chief medical editor of Modern Aesthetics®.
Price Transparency Ups Conversion Ratios
Price transparency provided via an online cost estimator can help plastic surgeons improve conversion ratios. When compared with non-price-aware patients, price-aware patients were 41 percent more likely to book a procedure, according to a study in the May 2016 issue of the Annals of Plastic Surgery.
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A San Francisco plastic surgeon integrated a cost estimator into his website during his first year in private practice in a new city. The calculator allows visitors to submit a “wishlist” of procedures to check pricing on these procedures, but they must submit their contact information to receive the information. The website received 412 wishlists from 208 unique consumers. Consumers (17.8 percent) that submitted a wishlist came in for a consultation and 62 percent of those booked a procedure. The average value of a booked procedure was more than $4,000 and cumulatively, all of the leads from this one lead source in that first year generated more than $92,000 in revenue.
“Plastic surgeons worry patients will price shop, won't realize prices can change based on patient's needs or body habitus and that competitors will check their prices,” says study author Jonathan Kaplan, MD, MPH, a plastic surgeon at Pacific Heights Plastic Surgery in San Francisco and Founder/CEO of KP Innovations, parent company of BuildMyBod Health, the price transparency platform used in this study. “By using the platform, consumers only get a price estimate after they provide their contact info so both the provider and consumer benefit: The consumer automatically gets specific pricing information on a specific procedure from a specific provider (something they can't get anywhere else) and the provider gets the consumer's contact info for follow up —a lead,” he says. “Because all of the doctor's prices are uploaded into a doctor-provided pricing database, the consumer receives pricing info in an automated fashion instantly. No time spent by the front office staff manually providing pricing info.”
Sticker shock definitely exists, he says. But “it's silly to have a patient come in for a 45-minute consult (many doctors offer a free consult) and have that patient expose their deepest insecurities only to find out the procedure is out of their budget,” he explains. “Price is the ultimate pain point. Why wait till the patient has wasted all of that time in a consult to find that out.”
HOORAY FOR HOLLYWOOD
BY WENDY LEWIS
For four days, an impressive roster of facial plastic surgeons, plastic surgeons, dermatologists, and oculoplastic surgeons convened at California's Beverly Wilshire Hotel to present and debate facial techniques in dynamic panels, interactive workshops, and uber-popular live surgery sessions.
The American Academy of Facial Plastic and Reconstructive Surgery's (AAFPRS) Facial Rejuvenation Meeting in Beverly Hills included a strong focus on advanced rejuvenation techniques, pearls for surgical and nonsurgical facial rejuvenation and avoidance and management of complications.
“We had an all-star line up that featured Dr. Paul Nassif speaking on the challenges and successes of patients seen on his hit show Botched (E! TV),” says Conference Chair Rami Batniji, MD, a Newport Beach, CA facial plastic surgeon. Dr. Nassif, a Beverly Hills facial plastic surgeon, gave a candid and enlightening talk about his bromance with plastic surgeon Terry Dubrow, MD and the unique challenges of patient selection and screening for revision surgery being performed on television.
Live from Beverly Hills
Course Director Theda C. Kontis, MD, a Pikesville, MD, facial plastic surgeon, worked diligently to incorporate live surgery into the conference, which was a huge draw for this event. Surgery was performed at the Beverly Hills clinic of Drs. Toby Mayer and Richard Fleming so that the audience could observe and learn from the guest surgeons.
The mix of attendees “allowed for a multidisciplinary view of surgical and non-surgical approaches, all in the name of further refining aesthetic results for their patients,” says New York Facial Plastic Surgeon Andrew Jacono, MD.
Chevy Chase, MD dermatologist Rebecca Kazin, MD agreed. She participated in the live injection demonstrations of both on-label and off-label techniques. “It was a great opportunity to learn from some of the masters, and share my own experience with fillers, toxins and other non-surgical treatments,” she says.
“The meeting provided a great mix of medical specialties dedicated to cosmetic facial rejuvenation that was well complemented by the live surgery demonstrations. I learned a lot, mainly about facelifting, which was my primary topic of interest. I was hopefully able to provide some insight into how to manage the aging Asian eyelid, and on volume restoration with facial fat grafting,” says Dallas facial plastic surgeon Samuel M. Lam, MD
Less is More
A key learning from the conference was the idea that more is not always more when it comes to facial surgery, says AAFPRS President Edwin F. Williams, MD, a facial plastic surgeon in Latham, NY. “We now have the means, ability, and technology to implement more innovative, less invasive techniques, and that can lead to overcompensation or overcorrection,” he says. “Even if it's easier than ever before to make a lip plumper or cheek more lifted, you still want the result to be subtle.” Female leading oculoplastic surgeons, including Drs. Julie Woodward of Duke University in Durham, NC, Lisa Bunin of Allentown, PA and Elba Pacheco of Severna Park, MD presented tips and techniques for periorbital rejuvenation.
Many of the speakers noted a distinct shift away from the skeletal, tightly pulled appearance of facial plastic surgery that was popularized in the 1990s. “Today's patients are sophisticated and understand that volume is key to a youthful face,” says Dr. Williams. San Francisco plastic surgeon Timothy Marten, MD provided his view on facelifting and fat grafting as the “dynamic duo.” He presented his unique expertise and technique refinements for restoring the periorbital area with an artistic use of fat grafts.
There were many discussions on the best uses for dermal fillers. “Sculptra® Aesthetic (Galderma) has excellent longevity and results can last up to three years after three treatment sessions,” Dr. Williams says. “It has the ability to restore volume and improve skin tone, and is an excellent choice for patients who do not have enough natural fat of their own to sculpt cheekbones and correct age-related volume loss.”
Greenwich, CT facial plastic surgeon Neil Gordon, MD presented the one contrarian lecture of the conference: “The Illusion of Volume Loss,” which was based on a chapter he wrote for Facial Plastics Clinics. “The key point I define is there is no scientific evidence of facial fat loss but substantial evidence of specific facial soft tissue gravitational changes,” he says. Dr. Gordon also presented his research from Yale University, which was the first to quantify skeletal aging effects on a single person over time.
“Overall, an illusion of volume loss is created in aging because the ‘container' (facial superficial soft tissue envelope) enlarges with the fat volume remaining constant,” he explains. “ A larger container holding the same volume appears as ‘half empty'. The only actual volume loss proven has been skeletal bone loss, which is in the same regions that respond best to volume injections. This occurs in the more extremes of aging and explains treatment limitations in the over 70 age group,” Dr. Gordon says.
Peeling Back The Years
Chemical peels remain a gold standard for improving skin quality, although they may not be considered as sexy as energy-based devices to many patients. Several AAFPRS members offered their experience with mild-to-moderate peels as an alternative and/or as an adjunct to resurfacing lasers to improve fine lines, tone and texture, as well as acne scars and uneven pigmentation with minimal downtime. Deeper trichloroacetic acid (TCA) peels are a perennial favorite for retexturizing and wrinkle reduction.
“Microneedling is also picking up momentum because it is easily delegated to physician extenders, it is non-invasive and delivers visible results,” says Dr. Williams. “We are using microneedling for treating acne scars, aging skin and pigmentation. It can be combined with peels, topical agents, and platelet rich plasma (PRP) to further enhance results.”
Save the dates: The AAFPRS Fall Meeting 2016 will be held from October 6-8, 2016 in Nashville, TN.
Wendy Lewis is President of Wendy Lewis & CO Ltd, a marketing and social media boutique in New York City, and Founder/Editor in Chief of beautyinthebag.com. Reach her at WL@wendylewisco.com.