Vol. 3, No. 6 – August 2004

Welcome to our August email update.


web_cos_sgyIt’s truly amazing how quickly the Internet has permeated our life and the impact that it has had not only on our personal life but on our professional life as well. It seems like only yesterday when we first placed our web site on the Internet although it has probably been at least five years. We are now averaging somewhere around 6000 to 9000 hits per day.

We have been delighted to have seen patients from around the world who initially found out about us from our website. We have tried to make the site a truly educational experience and avoid the overtly promotional aspects that are so characteristic of many cosmetic surgery sites. Apparently we have been successful based upon the response that we receive through personal comments and e-mail messages. Additionally, we frequently find ourselves high on the list among search engines in spite of the fact that we have never attempted to promote the website or pay to have it placed in a more favorable position.

E-mail has become an important tool for us to use in communicating with our patients. Not infrequently, patients who feel they may be experiencing a problem use e-mail to inform us about the difficulty and often combine their message with photos to document the problem. Granted, e-mail is not entirely secure and confidential. Nevertheless, most patients do not feel that the minor threat of a possible breach of confidentiality offsets the advantage of the instant communication.

Sometimes patients also use e-mail as a means of establishing a consultation. The initial groundwork is set up through e-mail including the transmission of photographs, after which the telephone consultation can be scheduled. Now we have a new and exciting tool at our disposal. This is a video communication over the Internet. Spearheaded by Apple’s new technology, Isight,we can have a live face to face consultation with our patients. Currently, this is limited to those with Macintosh technology although I’m sure it will be available soon in the PC world.


In spite of the best efforts on the part of the manufacturers, surgeons and patients, firmness following breast augmentation continues to be a significant problem. Unfortunately, technology has still not become available that eliminates a tendency on the part of some patients to develop a thick or contracted scar around the implant. Years ago an implant was available which had a polyurethane covering over the silicone. This implant was extremely resistant to scar contracture. Unfortunately, the technology is no longer available in the United States although it is still used in some other countries with great success.

The management of capsular contracture can be difficult. While some surgeons feel that aggressive massage techniques may be of benefit, we have never been convinced that it makes any difference. For the most part, we still have no idea why some patients develop contracted scars while most do not. As a matter of fact, frequently the contracture is limited to one side while the other is perfectly normal.

Certainly nothing need be done if the problem is relatively mild. On the other hand, if it becomes more severe, the consequences can be extremely unpleasant. Pain, tenderness, disfigurement and asymmetry are just some of the problems that can result. Unfortunately, there is no nonsurgical technique that is of any real benefit. Several years ago, we developed an endoscopic technique that has proven highly successful in the management of capsular contracture.

A very small half an inch incision is made just below the nipple. Dissection is carried down through the capsule wall and a small endoscope is inserted. Doctor Tobin and Rudy Garza, surgical technician at the Center, specially designed the endoscope. The endoscope has a laser attached that allows us to very precisely cut through the thickened, contracted scar tissue without injuring the implant.

An added important benefit is the complete absence of bleeding during the surgery. This is important because it is known that one of the factors that can contribute to the development of capsular contracture is the presence of blood around the implant.

Patients also appreciate the fact that recovery is generally prompt and easy with this procedure. Rarely is it necessary to use any dressing other than a small tape “steristrip” over the incision. Not only have we achieved a very high degree of success, we have found that recurrence of the condition is relatively uncommon. Unfortunately, there are some patients who will continue to develop firm capsules in spite of every effort. Fortunately, most patients can be relieved of the problem.


A recent article in the Los Angeles Times sites alleged sweetheart deals between physicians and drug manufacturing companies. Specifically, the article talks about the relationship between a prominent Beverly Hills dermatologist and the company, Allergan that manufactures the popular drug Botox.

Botox is a purified form of a material called botulinum toxin, which blocks nerve impulses to muscles. When tiny amounts of Botox are injected into muscles, they relax. The effect lasts three to four months. Allergan’s successful promotion of Botox drove sales of the drug to $564 million in 2003, 32% of the company’s total revenue of $1.75 billion. Last year, the Society for Aesthetic Plastic Surgery said Botox injection had become America’s fastest-growing cosmetic procedure. Botox works well and there’s no question that it serves a valuable use in a modern cosmetic surgery practice. However, there is no getting around the fact that there is often far too much hype over new cosmetic procedures. In this particular case, the doctor involved was found to have received half a million dollars for his activities promoting Botox over the past three years.

PromoterJerome Kassirer, a former editor of the New England Journal of Medicine was quoted in the article as saying that Allergan, in asking more from some physicians than medical advice, was “turning doctors into sales reps.” As for this doctor: “It is clear he is being paid to promote the drug.

This doctor wasnít alone. Forty doctors, according to this article, were groomed by Allergan’s public relations experts to act as media spokesmen for Botox, and the company had three hundred doctor’s offices and medical clinics in its official network of Botox training centers, court documents show. Unfortunately, all too often articles appear in the lay press extolling the virtues of various treatments and citing experts success without ever mentioning whether or not these physicians are on the payroll of the companies who are manufacturing the products.

While this news article dealt with only one specific company, regrettably, this practice is pervasive within our industry. Far too often, laser companies as well as companies producing newer injectables and skin care regimens are guilty of the same practices. This results in information confusing to patients and physicians alike.

We feel that this is inappropriate. When doctors make presentations at medical seminars, they are required to announce any financial relationship that they might have with a product being discussed. No less of a disclosure should be the part of any article that appears in a newspaper, magazine, or on a television show. Patients deserve at least this much honesty.

That’s it for this month. As always, we appreciate your interest and welcome your suggestions.


Howard A. Tobin, M.D., F. A. C. S.

For general information: askdena@newlook.org or n41gt@newlook.org