Imaging a Nip/Tuck Nation

How the sharp rise in plastic surgery affects you

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Gone are the days when body image problems are solved through friends, exercise and counseling. Increasingly, more people are turning to the operating table to conquer battles over self-image. Find out how this mainstream trend of plastic surgery affects you and the future of imaging.

Zachary E. Gerut, MD, FACS (5W Public Relations)

The Montclair Breast Center is a multidisciplinary and comprehensive breast center offering screening, diagnosis and treatment under one roof. (Montclair Breast Center)

"Nip/Tuck," "Make Me Perfect," "The Swan," "Extreme Makeover" – with new television shows like these popping up on the tube, you're bound to see someone voluntarily subjecting themselves to the scalpel.

And life is imitating art. In fact, the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) says the nationwide number of facial plastic surgery procedures and injections increased 34 percent from 2000 to 2004.

Plastic surgery in the United Kingdom is also carving out a growing number of patients. According to the British Association of Aesthetic Plastic Surgeons, the number of people undergoing cosmetic surgery has gone up by a third in the past year in Britain.

While there are many answers to plastic surgeons' infamous question, "What don't you like about yourself?," there are even more reasons for why they think they need it. One common reason may surprise you: to be a cut above the rest at work.

According to AAFPRS, 22 percent of men and 15 percent of women who sought plastic surgery in 2004 did so for work-related reasons.

But regardless of whether or not people seek sutures for success at work, the sharp rise in plastic surgeries will undoubtedly affect the work you do and the radiology profession of tomorrow.

What's more, surgeries that require the most concern in the imaging world are also among the most frequently performed surgeries in America. A study published by the American Society of Plastic Surgeons (ASPS) ranks the top five cosmetic procedures among women in 2004 as:
1. Liposuction: 292,402 patients
2. Breast Augmentation: 264,041 patients
3. Eyelid Surgery: 200,667 patients
4. Nose reshaping: 195,504 patients
5. Facelift: 103,994 patients

And experts say liposuction, breast augmentation, facelifts and Radiesse injections – a non-surgical facial contouring filler – top out the list of procedures requiring attention and expertise in a post-op scan.

Liposuction

Zachary E. Gerut, MD, FACS, a diplomat of the American Board of Plastic Surgery, says the most common and significant of all plastic surgery procedures affecting radiologic testing is breast augmentation. But one procedure that produces temporary effects and can distort an image is liposuction, as it leaves traces of air in the soft tissues.

"Clearly, air in the soft tissues is ominous [in] radiologic findings if [the] patient is being worked up for sepsis," Gerut says. "The history of recent liposuction must be taken into account in such cases."

Allen D. Rosen, MD, medical director of the Plastic Surgery Group in Montclair, N.J., says liposuction of the breast has recently become a frequently performed procedure. And as its popularity grows, so does the research about its after effects.

"At approximately one year, the scar changes seen in the breast following breast liposuction [is] usually within normal limits, [but] prior to one year's time, scar tissue or oil cysts may show up on mammographic evaluations," Rosen says. "Long-term calcifications from liposuction have not been predominant, [but] might be anticipated with greater application of this technique."

Nancy Elliott, MD, FACS, surgical oncologist and founder and director of the Montclair Breast Center (MBC) in N.J., says women undergoing any type of breast reduction surgery should have a mammogram and ultrasound immediately prior to their surgical procedure. "And if they are a high risk, they should have a breast MRI also," she explains. "A year later, when they have their annual screening mammogram, there will be changes apparent that may require a six-month follow-up."

Radiesse Injections

Radiesse injections are said to provide a longer-lasting result than many of its predecessors. This injectable filler is often used for reduction of smile lines and nasolabial wrinkles, cheek contouring, chin reshaping and jaw line contouring.

But be aware of this injection fluid, Gerut says, because Radiesse is made of artificial bone mineral. "These injections will appear as streaky calcifications, usually in the lips as it is injected for lip enlargement. In the lips, it usually lasts a year," he explains. "Most radiologists are familiar with the use of the substance for stress incontinence. Patients treated by urologists with this material will have a calcification of the bladder neck."

However, you might not have to worry about spotting this streaky injection on film for much longer. According to ASPS, the use of Radiesse injections is on the decline. From 2003 to 2004, statistics show a 9 percent decrease. But you may have to be on the lookout for permanent lip augmentation – which uses material other than injectables – as those procedures made a 44 percent jump over the past four years.

Facelifts

Women aren't the only ones getting facial plastic surgery these days. Rosen says a growing number of men are, too. "The population of men having surgery in 2004 was approximately 11 percent and the number in our practice [is] closer to 15 [or] 20 percent," he says. "These are professional men who are undergoing procedures like eyelid surgery, hair restoration and male breast reduction, as well as liposuction and face lift procedures."

But, Botulinum Toxin, better know as Botox™, is quickly becoming the most popular option for reducing wrinkles on the face and neck such as crow's feet, brow furrow and forehead lines. The effects of Botox™ are only temporary, but the injections can be done quickly, require no recovery time and are not as complicated as many other cosmetic procedures for the face.

Over the past four years, ASPS says, Botox™ usage has hiked 280 percent. And as consumers choose this non-surgical injection option, the number of people getting facelifts decreases. But, the ASPS says approximately 114,000 facelifts are being performed each year as of 2004, which means it's still a concern of yours.

"Certain soft tissue anatomic landmarks will be affected by facelifts," Gerut says. "If the platysma is tightened to the anterior border of the sternomastoid muscle, the shape of that may also be temporarily distorted."

Breast Augmentation

Virtually any woman who must lose her breast to cancer can have it rebuilt through reconstructive surgery. But there are risks associated with any surgery and specific complications associated with this procedure.

Rosen says women – whether they're undergoing a reconstruction or simply wanting a boost with an augmentation mammoplasty – must be informed of the risks associated with implantable devices during their consultation.

Gerut recommends submuscular saline implants to all of his breast augmentation patients. "I tell my patients that if a breast implant is placed above their muscle, it will be very difficult for their mammogram to be read," he says. "I tell them that if a breast implant is placed under the muscle, it looks more natural, it feels more natural, and they will be able to get mammograms that will be readable as long as the Eklund maneuver is done."

Rosen says the Eklund, or oblique, mammographic views are sufficient in performing routine mammographic surveillance in women with implants in place. "We do advise patients to specifically let their mammographer know that they do have a breast implant in place so that these additional views and/or additional diagnostic studies may be performed as necessary," he adds.

But, it's not just the implant that's of concern. Tissue expanders used during breast reconstruction, for example, have metallic-based fill ports that will show up on plain film and may interfere with MRI exams. "Any radiologist looking at plain films or other exams with fill ports in place should know that the device does have metallic portions of it and take appropriate precautions," Rosen explains.

A breast MRI is the best imaging modality to check the integrity of silicone implants, according to Elliott. Yet, mammography is still the standard of care for early detection for women with or without implants. Instead of the traditional four views, Elliott says eight views need to be done if a woman has implants – four on each breast, in order to see the breast tissue.

Interestingly enough, several Canadian studies have shown implant patients having as good of surveillance for breast disease as non-augmented patients, if not better. Rosen says, "It was postulated that perhaps patients with implants are able to perform exams with more ease as the breast tissue is more compressed." In any case, Rosen says he tells women – despite the controversy over mammography quality with breast implants in place – it is generally accepted at this time that excellent mammographic surveillance can be achieved in patients with implants today.

"Women often ask me, "Does having implants obscure or make it difficult to detect cancer?'" says Elliott. "My response is [to go to] a facility that is trained to do mammography with implants." The mammography technique performed for women with implants is a special skill that a mammography technologist must thoroughly learn, she adds. That's where her facility's unique setup comes in handy.

An Image of the Future

Elliott's MBC shares its facilities with Rosen's practice, the Plastic Surgery Group. It is a multidisciplinary and comprehensive breast center offering screening, diagnosis and treatment under one roof. The facility operates with the help of two breast imagers and two breast surgeons, among a large number of other trained staff.

While it typically takes five to six weeks from noticing a breast disease-related problem to the time of the surgical procedure, MBC streamlines the mammogram, ultrasound and biopsy to approximately two hours. Also, even in the case of a large breast cancer, Elliott has immediate help with reconfiguring the breast, thanks to MBC's on-hand plastic surgeons.

"We have been successful in developing a center of excellence in the care and treatment of patients' breast health. This was a natural consequence of our close working relationship that developed out of the treatment of breast cancer patients requiring mastectomy and reconstruction," says Rosen. "This led to the development of a facility, whereby we were geographically and physically connected, and the presence of the diagnostic imaging, MRI, digital mammography and surgery center fell into place."

The ability for patients to be diagnosed by a surgical oncologist, have diagnostic testing at the breast center, obtain plastic surgical consultation regarding breast reconstruction, reduction, lift and augmentation, while having an adjacent surgical center where needle localizations and MRI lobe biopsies can be performed, has provided a surge to both practices, according to Rosen. And he thinks the vertical integration model from a business point of view is one that will soon catch on elsewhere.

"[It's] an outstanding center of excellence because of the personnel brought together during this endeavor," says Rosen.

"I do believe that there will be more and more examples of strategic partnerships forming in medicine that provide anchor tenants in a facility and internal network opportunities for practices that want to share resources, expertise and equipment."