priscilla presley plastic surgery

2006-01-01T13:28:00.000-05:00

EVANSTON, Ill., March 7 /PRNewswire/ -- After the leaky mitral valves in their hearts were repaired non-surgically with a tiny, catheter-fed clip, nearly all -- over 90 percent -- of the patients whose mitral regurgitation (MR) was significantly reduced one month after receiving the clip maintained the reduction at six months. In addition, 75 percent of the patients who received the clip as part of a Phase I clinical trial are still surgery-free.

Mitral regurgitation is a debilitating condition that occurs when the mitral valve, which allows blood to move through the heart, fails to close properly.

"As we get more experience with this procedure, we're seeing that our ability to control the MR is increasing and the time it takes to accomplish the repair is decreasing. With this device, we can provide a minimally invasive option for decreasing valve leakage without taking away the patient's ability to have surgical valve repair in the future, if it's needed," says Principal Investigator Ted Feldman, MD, Director of the Cardiac Catheterization Lab at Evanston Hospital, flagship of the Evanston Northwestern Healthcare system.

Evalve, Inc. (Redwood City, CA) developed and manufactures the MitraClip(TM). The clinical trial is known as EVEREST I, Endovascular Valve Edge-to-Edge Repair Study.

Dr. Feldman will present results of the EVEREST I trial today at 3 p.m. in Room 414-A at the American College of Cardiology's 54th Annual Scientific Session being held in Orlando, FL.

The presentation, part of the Oral Contributions: Percutaneous Valve Procedures Session, is titled Percutaneous Edge-to-Edge Mitral Valve Repair Using the Evalve Clip: Update on the EVEREST Phase I Clinical Trial.

To date, a total of 27 patients with severe mitral regurgitation have been enrolled in the trial. Dr. Feldman performed the first U.S. procedure in Evanston Hospital's Cardiac Catheterization Laboratory. Other U.S. investigators participating in the trial are: Hal Wasserman, MD, Columbia University Medical Center, New York; William Gray, MD; Swedish Medical Center, Seattle; Howard C. Herrmann, MD, University of Pennsylvania; Peter C. Block, MD, Emory University Hospital, Atlanta; and Patrick L. Whitlow, MD, Cleveland Clinic Foundation. Elyse Foster, MD, University of California, San Francisco, is Director of the Echocardiographic Core Lab.

"As a group, we have seen minimal rates of complications occur during the procedures. We've also seen that for the majority of patients who achieve good initial results, favorable results are sustained. The patients who did not receive optimal MR control with the clip were able to have routine, conventional mitral valve surgery," explains Dr. Feldman.

Moving forward

Nationwide, study centers will soon begin enrolling eligible patients in EVEREST II, a prospective, randomized, multi-center study that will compare the clip approach with open-heart valve surgery. For information about study centers, visit http://www.evalveinc.com/ .

"The promising results that we've seen from EVEREST I justify moving this study forward," says Dr. Feldman. "This is one of several new devices that will help us improve faulty heart valves without the downtime of surgery," says Dr. Feldman.

About the procedure

Performed in a cardiac catheterization laboratory under general anesthesia, a catheter (a thin, flexible plastic tube) introduced through the skin in the thigh area, is guided from the femoral vein to the affected area of the valve in the heart. The clip is precisely steered into place and attached to the mitral valve, helping it to close properly. Once the clip is securely attached, the catheter is removed.

The procedure is performed using echocardiography and fluoroscopy. Patients typically spend one or two nights in the hospital and return to normal activity within one week.

In chronic MR, blood leaks backward with each heartbeat, requiring the heart to work harder. It's a progressive disorder that affects approximately 4 million people in the United States. Approximately 250,000 patients develop significant mitral regurgitation annually in the U.S. Most of these patients eventually become so weakened by the condition that they require open-heart surgery with cardiopulmonary bypass. Approximately 50,000 people a year have open, arrested-heart mitral valve surgery.

Last week, a study in the New England Journal of Medicine indicated that even patients with severe MR who do not yet have clinical symptoms obtain a significantly greater survival benefit from surgery compared to treatment with medication and delayed surgery. (Enriquez-Sarano, M., Quantitative Determinants of the Outcome of Asymptomatic Mitral Regurgitation, 352:875-883)

About Evanston Northwestern Healthcare

Located in Chicago's northern suburbs, Evanston Northwestern Healthcare (ENH) is an integrated healthcare system that includes Evanston, Glenbrook and Highland Park Hospitals, ENH Medical Group (comprising 65 medical offices and facilities), ENH Home Services, ENH Research Institute and ENH Foundation.

Through its affiliation with Northwestern University's Feinberg School of Medicine, ENH supports extensive medical education and research programs. ENH is in the top 9 percent of all institutions that receive funding from the National Institutes of Health; among multi-specialty independent research hospitals it ranks 12th in the nation.

ENH is also recognized as a leader for implementing technology and improving processes to advance the safety and quality of patient care. Its hospitals are the only ones in Illinois to have fully implemented the quality and safety practices recommended by the Leapfrog Group for Patient Safety*. Hospitals and Health Networks magazine has named ENH one of the "Most Wired" healthcare organizations in the nation.

   * 2004 Leapfrog Hospital Quality and Safety Survey 
 
   ACC Presentation # 816-7 
   (Control/Tracking Abstract #05-A-317921-ACC)

CONTACT: Anne Dillon of Evanston Northwestern Healthcare, +1-847-570-3146, adillon@enh.org , or Jim Weiss for Evanston Northwestern Healthcare, +1-415-692-4213, jim@weisscom.net

Web site: http://www.evalveinc.com/

2005-12-29T22:02:00.000-05:00

A tax on cosmetic procedures, already a reality in New Jersey, is causing concern among physicians in Illinois who fear their state may be next.

Late last year, Illinois State Comptroller Dan Hynes proposed a 6% tax on cosmetic procedures; revenues from the tax would be used to fund stem cell research. "Stem cell research promises to revolutionize the practice of medicine and spark treatment advances that could eventually improve the quality and duration of life for millions of Americans," Mr. Hynes said in a statement. "I intend for the medical community of Illinois to be on the front lines of that revolution."

Mr. Hynes noted that the state already faced "great financial difficulties" but added, "I want to be very clear here: What I am proposing is self-funded by this very narrowly defined luxury tax that is applicable to less than 2% of the population."

He estimated that the tax could raise enough money to fund both the initial $15 million needed for the research as well as debt service on a $1 billion bond issued for ongoing funding. The comptroller's office is planning to present a full proposal to the state legislature "in the spring," according to a spokesman for Mr. Hynes, who added that it "won't be a problem" to get a legislator to sponsor the bill.

The American Society of Plastic Surgeons blasted the proposal. "This is not the 'luxury tax' that Mr. Hynes would like the public to believe," ASPS President Scott Spear, M.D., said in a statement. "Plastic surgery, as the statistics illustrate, has become more mainstream. It is not just an indulgence of celebrities and rich people. It is a reasonable option for anyone who wants to look or feel better about their appearance."

Elvin Zook, M.D., past president of the ASPS, called the proposal "a grandstand play by the state comptroller, who's politically motivated."

He warned that taxing one kind of surgery could lead to other surgery taxes. "So you have an artificial knee; why not tax that?" asked Dr. Zook, who is professor of plastic surgery at Southern Illinois University, Springfield.

In New Jersey, where a similar tax--also at 6%--went into effect last September, physicians are seeing the results.

"An hour ago I had a patient call in who had seen me in consultation, and wanted to go ahead with significant surgery, but she is going to see someone in New York because she doesn't want to pay the tax," said Richard D'Amico, M.D., chief of plastic surgery at Englewood (N.J.) Hospital and Medical Center. "When you're talking about a $10,000 or $20,000 surgical bill, that's some real money." For example, a 6% tax on a $20,000 procedure would amount to an extra $1,200.

The New Jersey tax includes both less invasive procedures such as Botox injections and facial peels, and more invasive procedures such as liposuction and facelifts. Legislators expect the tax to bring in $26 million to help cover uncompensated hospital care in the state, but it may not work out that way since many doctors who also have offices in nearby New York or Philadelphia are simply switching their procedures over to those states instead of doing them at New Jersey facilities, Dr. D'Amico said. "It's very ironic that [the hospitals] will be hurt the most by this."

But officials at the New Jersey Hospital Association aren't worried. "I don't think it would put a dent into the $26 million, unless everybody fled," said NJHA spokesman Ron Czajkowski, in Princeton.

In addition to the cosmetic surgery tax, the state legislature also enacted a 3.5% gross receipts tax on freestanding ambulatory surgery centers (ASCs); that tax is capped at an annual maximum of $200,000 per facility. Physicians who perform cosmetic procedures and who have an ownership interest in an ASC are affected by both taxes.

The cosmetic procedure tax is fraught with other problems besides lost business, according to Peter Hetzler, M.D., president of the New Jersey Society of plastic Surgeons. For example, "there are a huge number of procedures that have both functional and cosmetic components to them, and how do you determine what gets taxed and what doesn't?" said Dr. Hetzler, who is in private practice in Little Silver, N.J.

He cited the example of a patient who has significant airway obstruction and gets a rhinoplasty to fix the sinuses, septum, and turbinates; the surgery may also affect the look of the nose. "'We have to find a way to divide that up."

Using CPT codes to designate which services will be taxed is not necessarily a solution, Dr. D'Amico said. "The code for a cosmetic breast lift is also the code for [restoring] symmetry in a woman who has had a mastectomy, but one is reconstructive and shouldn't be taxed," he said. "None of that has been worked out."

Dr. Hetzler has formed the Coalition of New Jersey Medical Professionals, a group of medical providers affected by the tax. The coalition is working with state taxation officials to figure out how to implement various aspects of the regulation, including the issue of how to tax procedures that are only partly cosmetic.

The coalition has little hope that the tax will be repealed, especially in the face of the state's large budget deficit, Dr. Hetzler said. But he is pleased that taxation officials have been cooperative and are willing to work with the coalition "to make sure that they don't indiscriminately audit physicians who may be at the mercy of patients paying this tax."

Naomi Lawrence, M.D., a spokeswoman for the American Academy of Dermatology, said that she was concerned that the tax idea may spread to other states.

"Everybody's looking for a way to cover charity care; they are desperate to find some way to do it," said Dr. Lawrence, chief of procedural dermatology at Cooper University Hospital, Marlton, N.J. "It's one of those ideas that's very popular with hospital associations across the country."

Dr. D'Amico agreed, noting that New Jersey's tax, which was passed without any input from affected providers, should serve as a warning to providers in other states. "'They should be careful in whatever state they're in that this doesn't come up," he said.

2005-12-23T11:46:00.000-05:00

CINCINNATI, March 29 /PRNewswire/ -- Plastic surgery is featured in the media more than ever before, from prime time reality television shows to monthly magazine stories, but despite all of the hype, it is still major surgery with real risks and complications. Following are a few key questions to ask your prospective surgeon, as well as what you need to know about your own lifestyle, before you undergo surgery:

   - Make sure that your physician is board certified by The American Board 
     of Plastic Surgery. Many physicians practicing as plastic surgeons 
     advertise that they are board certified, but they don't mention what 
     their certification is in a different medical specialty, such as 
     ear, nose and throat, oral surgery, etc. 
 
   - Get references from friends or acquaintances whom have had a similar 
     procedure done by that plastic surgeon. 
 
   - The plastic surgeon should also be comfortable showing before and after 
     photographs of his/her patients, as well as having former patients 
     discuss their procedures with you. The surgeon should also be 
     comfortable discussing how many of these procedures they have 
     performed. Be very realistic about the procedure and results. 
 
   - The surgeon should have hospital privileges to do that procedure. Any 
     surgeon can perform any surgery in his/her own facility. Only 
     appropriately qualified surgeons can do the same procedure in a 
     hospital or ambulatory surgery center. Make sure the surgical facility 
     is appropriately accredited. 
 
   - Some health issues also need to be considered. Smoking is one of the 
     two most detrimental external influences you can have on your aging 
     process, skin, and the results of your surgery. You should completely 
     quit at least two weeks before the surgery to allow your body and lungs 
     to clear some of the damaging chemicals such as carbon monoxide. The 
     other detrimental influence is excessive sun exposure. 
 
   - For the best results, you should be in reasonable shape regarding your 
     weight and exercise regime. Your blood pressure and any diabetic risk 
     factors should also be under control. 
 
   - The surgeon should also give literature about the procedure, as well as 
     discuss possible risks and potential complications. No procedure is 
     without risk and this should be clearly communicated in the 
     consultation and preoperative discussions. 
 
   - The surgeon should be very realistic about the recovery process rather 
     than give a best-case scenario. Too often a patient is told that the 
     recovery will be short and easy when there may be bruising, swelling, 
     and additional time needed.

Dr. Lawrence Kurtzman is a board certified plastic surgeon with The Plastic Surgery Group. With offices in Cincinnati, Ohio, and Crestview Hills, Ky., The Plastic Surgery Group is one of the largest non-academic cosmetic surgery practices in the nation. The physicians work with patients to provide plastic surgery procedures including liposuction, tummy tucks, skin care, hair removal, face lifts and breast enhancement, allowing patients to look great at every age. More information can be accessed at http://www.theplasticsurgerygroup.com/ .

Available Topic Expert(s): For information on the listed expert(s), click appropriate link. Lawrence C. Kurtzman, M.D., F.A.C.S. http://profnet.prnewswire.com/ud_public.jsp?userid=482965

CONTACT: Susan McDonald of The Plastic Surgery Group, +1-513-388-4700, ext. 3014

Web site: http://www.theplasticsurgerygroup.com/

2005-12-21T04:54:00.000-05:00

1588903192

Facial plastic surgery; the essential guide.

Park, Stephen S. et al.

Thieme Medical Publishers

2005

312 pages

$139.95

Hardcover

RD119

Scholars of plastic surgery at various US universities offer a comprehensive guide to the essential elements of facial plastic and reconstructive surgery, to serve young physicians just beginning plastic surgery practice as a foundation for further study. They cover syndromes and congenital anomalies, cutaneous lesions and facial reconstructions, head and neck reconstruction, maxillofacial and soft tissue trauma, rhinoplasty, and aging-face surgery. The illustrations are drawings and black-and-white photographs.

([c] 2005 Book News, Inc., Portland, OR)

2005-12-15T04:46:00.000-05:00

BEVERLY HILLS, Calif. -- With an insatiable worldwide appetite for plastic surgery, a new demand has been created for Beverly Hills to take their world of "nip & tuck" across the pond. This Wednesday, April 13, 2005, in conjunction with Endemol Productions and Channel 5 (UK), world-renowned Beverly Hills plastic surgeon Toby G. Mayer, M.D. will perform a new FDA-approved facial rejuvenation procedure and broadcast it LIVE to the United Kingdom on a new documentary series titled, "Cosmetic Surgery Live."

"The demand for more education and real people to share their experiences with plastic surgery has grown incredibly all over the world," explained Dr. Mayer, co-director with Richard Fleming, M.D. of the Beverly Hills Institute of Aesthetic and Reconstructive Surgery. "We are excited to participate in a show like 'Cosmetic Surgery Live,' which takes the epicenter of beauty (LA) to the United Kingdom."

Dr. Mayer will perform a new FDA-approved procedure called the ENDOTINE Cheek Lift which is ideal for patients ages 35-50 who are not looking for a radical makeover, but a more understated rejuvenation that brings them back 7-10 years. With its five points of contact and absorbable features, the new ENDOTINE device gives patients natural, long-lasting results. It also enhances cheek volume - key to obtaining a more youthful appearance.

During a cheeklift procedure using ENDOTINE, a half-inch incision is made inside a "crows foot" alongside the lower eye. Once the underlying muscle and tissue has been elevated to "lift" the cheek area, the new ENDOTINE Mid Face is placed to capture and elevate the cheek, securing it into the bone and holding it in position until the soft tissue re-adheres to the cheek bone entirely. The ENDOTINE gradually absorbs completely, at which time the tissue is securely attached to the cheekbone lifting the mid-face.

Prior to ENDOTINE, surgeons could only suspend cheek tissue with one point of fixation via a single suture. The weight and stress on the suture usually became too cumbersome, causing pulling of the cheek area. Patients complained of cheek dimpling, and, in some cases, complete reversal of the procedure.

"The new cheeklift procedure is ideal for patients who have drooping in their mid-face and/or a hollow look under the lower eyelids," explained Dr. Mayer. "Our patients are pleased that while recovery time is short, the results are dramatic and long lasting."

Drs. Fleming and Mayer are co-directors of The Beverly Hills Institute of Aesthetic and Reconstructive Surgery and Clinical Professors and immediate past chairmen of the Division of Facial Plastic and Reconstructive Surgery at the University of Southern California School of Medicine. They are dual-board certified/members of the American Academy of Facial Plastic & Reconstructive Surgery. Visit www.bevhills.com. The ENDOTINE Mid Face device was developed and is manufactured by Coapt Systems of Palo Alto, Calif. and is based upon its patented MultiPoint Technology (MPT(TM)) platform. Visit www.coaptsystems.com.

2005-12-06T20:53:00.000-05:00

 ROUND-UPS 
 
 Flu Vaccine (continued, 1 expert) 
 Universal Health Insurance (continued, 1 expert) 
 
  LEADS 
 
  1.  Fitness: Is the 10,000-Step Walking Regimen for Everyone? 
  2.  Fitness: Giving the Gift of Fitness for the Holidays 
  3.  Health: Sleep Disorders Often Misdiagnosed As ADD 
  4.  Health: Plastic Surgery Now More Appealing Women and Men 
  5.  Health: One's Health is Directly Impacted By the Immune System 
  6.  Medicine: Patients Are Needed for Clinical Cancer Trials 
 
  ROUND-UP: FLU VACCINE (continued)

ProfNet has added the following to items posted previously at http://www.profnet.com/organik/orbital/thewire/lst_leads.jsp?iLRTopicID=1752

1. JAMES HUBBARD, M.D., M.P.H., family physician and publisher of Family Doctor: The Magazine That Makes Housecalls: "The general public should not panic regarding the shortage of this year's flu vaccinations. There should be plenty to go around for those who need it, such as the elderly, very young and chronically ill. Other healthy people are only at a small risk for major complications. If they get the flu, at worst, they will have a week or so of symptoms." Hubbard can provide practical advice on what to do if you get the flu. News Contact: Leigh Ann Hubbard, managingeditor@familydoctormag.com Phone: +1-719-964-7464 (10/28/04)

2. JIM MANN, executive director of the HANDWASHING FOR LIFE INSTITUTE, is an expert source on the topic of warding off the flu virus due to the flu vaccine shortage. News Contact: Ron Bottrell, ron.bottrell@hillandknowlton.com Phone: +1-312-475 5905 (10/28/04)

ROUND-UP: UNIVERSAL HEALTH INSURANCE (continued)

ProfNet added the following to items posted previously at http://www.profnet.com/organik/orbital/thewire/lst_leads.jsp?iLRTopicID=1004

1. SALLY PIPES, author of the new book "Miracle Cure: How to Solve America's Health Care Crisis and Why Canada Isn't the Answer": "We have to put the individual back in the driver's seat. Programs like Health Savings Accounts, moving away from employer-provided health insurance and Association Health Plans would dramatically lower the number of uninsured. What's more, every American could be insured tomorrow if the money devoted to regulating health insurance was spent instead on health insurance." News Contact: Laura Braden Dlugacz, ldlugacz@dcgpr.com Phone: +1-202-572-6231 (10/28/04)

LEADS

1. FITNESS: IS THE 10,000-STEP WALKING REGIMEN FOR EVERYONE? LEONARD KAMINSKY, professor of physical education and coordinator of adult physical fitness and cardio/pulmonary programs at BALL STATE UNIVERSITY: "While the U.S. Surgeon General is recommending the average person walk 10,000 steps a day to improve health, the program has come under fire for being less effective than other types of more strenuous exercise in improving fitness levels. The 10,000-step program is primarily targeted to sedentary or irregularly active people to promote health. The hope is that people will start slowly by walking and then actually transition to a more strenuous exercise program." News Contact: Layne Cameron, lscameron@bsu.edu Phone: +1- 765-285-5953 (10/28/04)

2. FITNESS: GIVING THE GIFT OF FITNESS FOR THE HOLIDAYS. KEVIN GRODZKI, president of LIFE FITNESS, a manufacturer of cardiovascular and strength- training equipment, can provide many home fitness equipment gift ideas: "Obesity is an epidemic that, unfortunately, is an extremely serious, very prevalent issue in today's society. So this holiday season, give the gift of good health and fitness to your loved ones. In 2003, Americans spent $5.5 billion (retail) on home exercise equipment. Sales continue to rise, with a projected increase to $5.8 billion in 2005." News Contact: Tracey Budz, tracey.budz@lifefitness.com Phone: +1-847-288-3456 (10/28/04)

3. HEALTH: SLEEP DISORDERS OFTEN MISDIAGNOSED AS ADD. DR. MERRILL WISE, physician with TEXAS CHILDREN HOSPITAL's Sleep Disorder Clinic: "Children who suffer from poor school performance, memory lapses and behavioral problems may have a relatively common and treatable sleep disorder. Sleep disorders may be undiagnosed or misdiagnosed, such as attention deficit disorder. Children may act out in ways that resemble hyperactivity when they just aren't getting enough sleep." News Contact: Laura Frnka, lafrnka@texaschildrenshospital.org Phone: +1-832-824-2645 (10/28/04)

4. HEALTH: PLASTIC SURGERY NOW MORE APPEALING. ROBERT R. HUMMEL, M.D. of THE PLASTIC SURGERY GROUP: "Once considered a secret among Hollywood celebrities, plastic surgery has exploded into the mainstream. Women and men from their 20s to upper 60s are taking advantage of the newest techniques to improve their skin or freshen their look. Plastic surgery has changed. People who wouldn't have considered a procedure 10 years ago are now seeking our services, and it falls across several generations." News Contact: Susan McDonald, smcdonald@jypublicrelations.com Phone: +1-513-388-4706 (10/28/04)

5. HEALTH: ONE'S HEALTH IS DIRECTLY IMPACTED BY THE IMMUNE SYSTEM. DR. BARBARA LEVINE, Ph.D., R.D., director of the Nutrition Information Center at CORNELL UNIVERSITY, can talk about the everyday factors that affect immune health, including yo-yo dieting, sun exposure, stress and even laughter: "Medical experts agree that our health is directly impacted by the immune system. It is the body's own protection mechanism that works hard to keep vital organs shielded from outside forces. It's astonishing that so few people are familiar with the everyday factors that can positively or negatively affect the immune system. It is so important to introduce this information to consumers and get them directly engaged in ways to maintain the body's natural defenses. People can do simple things everyday to support their immune health, including supplementing their diet." News Contact: Jennifer Humphrey, jhumphrey@hillandknowlton.com Phone: +1-323-966-5767 (10/28/04)

6. MEDICINE: PATIENTS ARE NEEDED FOR CLINICAL CANCER TRIALS. DR. GARY COHEN, administrative director of THE SIDNEY KIMMEL FOUNDATION FOR CANCER RESEARCH: "A shortage of adult patients is holding up clinical cancer trials. Patients often believe they'll receive a placebo, which is usually not the case. Family doctors are sometimes reluctant to refer a patient to a clinical trial for fear of losing that patient to an academic center. In some states, HMOs have curtailed insurance benefits for patients on clinical trials.

Patients believe that participation may require travel. Many trials can now be initiated by community-based physicians throughout the U.S. If some of these issues aren't addressed, few of the new breakthrough medications will be properly tested and developed." News Contact: Risa B. Hoag, risah@theprcollective.com Phone: +1-845-627-3000 (10/28/04)

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PRNewswire -- Oct. 28

2005-12-05T12:37:00.000-05:00

Klippel-Trenaunay syndrome (KTS) is a rare disorder that consists of a triad of capillary vascular malformation, venous malformations and/or varicose veins, and soft tissue and/or bony hypertrophy. Pain is a real and debilitating problem in these patients. We have observed 9 common causes of pain in KTS: (1) chronic venous insufficiency, (2) cellulitis, (3) superficial thrombophlebitis, (4) deep vein thrombosis, (5) calcification of vascular malformations, (6) growing pains, (7) intraosseous vascular malformation, (8) arthritis, and (9) neuropathic pain. The management of pain in patients with KTS depends on its cause. These patients are best evaluated initially in a center with an experienced multidisciplinary team that includes a primary health care provider, surgeons, and ancillary staff. The ongoing care of a patient with KTS often depends on a local provider who is more readily accessible to the patient but may not have the expertise of a large center to manage the complications of KTS. The purpose of this communication is to review the common causes of pain in these patients to provide local health care providers and patients and their families with appropriate management strategies. Pediatrics 2005;115:744-749; pain, pain management, Klippel-Trenaunay syndrome, vascular malformation, chronic venous insufficiency.

ABBREVIATIONS. KTS, Klippel-Trenaunay syndrome; DVT, deep vein thrombosis.

Klippel-Trenaunay syndrome (KTS) is a rare disorder that comprises the triad of (1) capillary vascular malformation, (2) varicose veins and/or venous malformation, and (3) soft tissue and/or bony hypertrophy. (1-4) It is a mixed malformation with soft tissue and bony malformations and is associated with predominantly venous, lymphatic, and capillary vascular malformations, with involvement of usually I of the lower limbs. Chronic lymphedema will frequently aggravate the clinical presentation. The manifestations of KTS are protean, and, in many patients, pain is a frequent and debilitating problem. We previously (5) reported that 38% of patients had significant pain, and Baskerville et al (6) found that 88% of their patients had pain. The lower extremity is most often affected in KTS, and pain is a great problem in these patients compared with those whose upper extremity is affected.

Over the past 25 years, we have collectively had the opportunity to evaluate and treat >300 patients with KTS. (5,7-13) On the basis of this experience, we have observed several different patterns and causes of pain. It has become clear that to deal appropriately with pain in patients with KTS, one first must define the exact cause of the pain. The purpose of this communication is to share our experiences so that patients with this rare problem receive the best possible care.

THE MAYO MODEL OF CARE FOR VASCULAR MALFORMATIONS

At Mayo Clinic Rochester, we use a multidisciplinary approach to the evaluation and treatment of patients of all ages with vascular anomalies, including KTS. The core of this team includes a pediatrician/family physician or internist and vascular, orthopedic, and plastic surgeons. In addition, the expertise of vascular internists of the Gonda Vascular Center, radiologists, physiatrists, pain management specialists, and dermatologists are employed. Periodically, formal reviews of our experience are conducted and published. The basis of this communication is the cumulative experience of this multidisciplinary team.

CAUSE OF PAIN IN KTS

We believe that there are 9 common causes of pain in KTS. Some patients may have only 1 cause of pain, but others may have several causes of pain.

Chronic Venous Insufficiency

Venous abnormalities are a hallmark of KTS. Superficial varicosities; persistent large superficial embryonic veins, usually in the lateral position in the leg; and deep venous valvular incompetence, aneurysmal dilation, hypoplasia, or aplasia are common. Varicose veins become more prominent and problematic with increasing age. Ambulatory venous hypertension is a well-defined entity because of increasing venous pressure after exercise as a result of valve incompetence or outflow obstruction. The discomfort that results from generalized venous congestion is poorly understood, but clearly, varicosities and venous malformations are more painful when distended with venous blood. The discomfort associated with venous incompetence is usually described as a "dull, achy" sensation and typically is more noticeable as the day progresses because of venous pooling of blood.

Varicose veins have been thought to result from primary valvular incompetence. Recent theories propose that decreased elasticity of vein walls cause dilation of the walls, leading to separation of the valve leaflets. (14) Others have shown that varicosities can result even without valvular incompetence. (15) Persistence of embryonic veins that normally regress during gestation is clearly a major cause of varicosities in KTS. Another plausible explanation that has been proposed for increased venous congestion is inefficient calf pump function. However, Baskerville et al (6) compared foot volumetry in normal patients and KTS patients and found no significant differences in reduction of foot volumes during exercise to suggest inefficient calf pump in limbs of patients with KTS.

Chronic venous congestion can lead to pigmentation, eczema, lipodermatosclerosis, varicosity, atrophy blanche, corona phlebectatica, and, ultimately, breakdown of the skin and ulcerations. It has been found that the severity of the skin ulceration correlates with the degree of ambulatory venous hypertension. (16,17) Patients with ambulatory venous pressure <40 mm Hg had a lower incidence of skin ulcers than patients with ambulatory venous pressure >80 mm Hg. (18)

The mainstay of treatment of this type of pain and discomfort is external compression of the venous system. It can be treated with elastic or nonelastic compression garments. It usually is best to use a closed-toe compression garment. The length of the garment is dictated by the extent of leg involvement. However, we have found that if the entire leg is involved, then a full-length pantyhose-type garment works best. This type of garment is least likely to drift downward while worn and also can provide compression to the groin and buttocks. The greatest pressure that the patient can tolerate should be used. Most patients can tolerate compression of 40 to 50 mm Hg. However, some patients cannot tolerate this level of pressure and will need compression of 30 mm Hg. Foot and leg overgrowth can present a challenge to fitting appropriately a support garment and a challenge to the patient to put on the garment. In some patients, it will be impossible to design a garment that can be applied because of a very large foot. These patients will have to be instructed in methods of wrapping the extremity with compression bandages. In rare cases of complete deep vein obstruction, patients with large superficial veins do not tolerate compression garments. Duplex evaluation of the venous anatomy in these patients is very important.

Frequent elevation of the extremity during the day is very important in reducing pain and the development of stasis ulcers. At all times, when it is possible to elevate the affected extremity, it should be done. We frequently recommend elevating the foot of the bed for good drainage of the venous system during the night. In severe cases, a patient may have to alter his or her occupation from a job that requires prolonged standing to one that allows the patient to sit and, preferably, elevate the leg.

In selected cases, surgical intervention, sclerotherapy, or endovascular laser ablation may be indicated in patients who are symptomatic with pain and edema. Asymptomatic patients are usually managed conservatively because of the high (50%) recurrence rate of varicosities. (9) In the highly selected group of patients who are considered for surgical procedures, a thorough assessment of the venous anatomy should be performed with duplex scanning, contrast phlebography, MRI, and magnetic resonance phlebography. Duplex scanning and ascending and descending phlebography are used to assess valvular incompetence of the deep, superficial, or perforator veins; discover deep venous anomalies and obstructions; and assess collateralization, respectively. Frequently, the abnormalities seen in KTS include persistence of embryonic veins, agenesis, hypoplasia, valvular incompetence, or aneurysms of deep veins.

The most common surgical treatment in patients with KTS is stripping of the veins and avulsion or excision of varicosities and vascular malformations. The primary goal of imaging is to confirm patency of the deep venous system before these procedures are performed. In a very rare subset of patients, removal of the tortuous but patent superficial venous system leads to venous hypertension if deep venous reconstruction is not also performed. Although most surgical procedures for varicosities are uncomplicated, it is often impossible to remove all varicosities because of the extent of involvement. Fifty percent of patients who have surgery will have some form of recurrent varicosities. Despite this, patients report subjective improvement in symptoms and an overall clinical improvement as reflected by a reduction in the clinical severity score after surgery. (9) Recurrent varicosities can and have been reoperated on if the benefits outweigh the risks of the procedure. Sclerotherapy of cavernous venous malformation with alcohol and foam sclerotherapy of the venous malformations have been used by others, with mixed results.

Cellulitis

Patients with KTS are prone to cellulitis, and whether this is attributable to an actual bacterial infection or an inflammatory response as a result of venous stasis, localized lymph accumulation, or thrombosis is not always clear. (19) Chronic lymphedema is clearly a major cause of cellulitis and lymphangitis. In our series, (5) 13% of patients had infectious cellulitis. These patients may be more susceptible to infection because of poor skin integrity or from venous pooling. Thus, it is imperative for patients to maintain excellent skin hygiene. Maintaining strict hygiene can be challenging because of hyperhidrosis associated with KTS that is accentuated by the use of stockings, shoes, etc. Particularly for patients with significant foot and toe involvement, thorough washing of leg, foot, and toes may be challenging. We encourage patients to wash the affected body parts thoroughly with soap and water twice a day. If the patient prefers showers to bathtubs, then we suggest that he or she place a stool in the shower so that he or she can sit and wash thoroughly between the toes. It is imperative that patients wear clean stockings every day and allow their shoes and feet to dry between shoe changes. These patients should avoid going barefoot.

For some patients, use of a compression garment will reduce the incidence of cellulitis, but in others, it may increase the risk for cellulitis because of the associated hyperhydrosis or because of abrasions of keratohemangiomas by the stocking. One must experiment with this to know which is best for individual patients.

If there is new-onset erythema, local discomfort, and warmth, then cellulitis always must be suspected. It is imperative to treat these patients with antibiotics as soon as the diagnosis is apparent.

Usually, patients who have had recurrent cellulitis are able to recognize the heralding symptoms of cellulitis up to 24 hours before the infection is clinically apparent. For these patients, we suggest that they have a 10-day supply of an appropriate antibiotic at home so that they can begin taking antibiotics at the first sign or symptom of cellulitis. In rare patients, this may not be enough to prevent serious recurrent cellulitis, and one must consider prophylactic antibiotics. We think that it is best in these situations to consult with an infectious disease expert to plan the most appropriate course of treatment for these rare situations.

Growing Pains

Growing pains are normal in healthy children. Children with KTS are just as likely to have growing pains as are healthy children. The muscles are affected more so than the joints, and the area is usually normal on examination with no evidence of erythema, skin ulceration, mass, or swelling. Compared with pain caused by other factors, that of growing pains is relieved by simple comforting measures such as holding, stroking, and massaging of the limb.

Thrombophlebitis

Inflammation of the superficial veins is common in KTS and, in our series, (5) occurred in 15% of patients. Aseptic inflammation probably results from venous stagnation in the lower extremity varicose veins. This type of pain is best treated with simple analgesics and antiinflammatory agents along with compression and elevation. If recurrent, then vein stripping, ligation, or injection sclerotherapy may be helpful. This should be undertaken only in a select group of patients in whom an intact deep venous system has been demonstrated. In patients with large embryonic veins or when the saphenous junctions are involved, anticoagulation should be considered.

When left untreated, superficial thromboses usually are a self-limiting problem. In 7 to 14 days, the pain subsides and a small knot may be palpable (the organized thrombus). These clots may calcify and become "phleboliths" that are apparent on radiographs. Treatment, if used, consists of nonsteroidal antiinflammatory agents and mild analgesics.

When a calcified phlebolith is on a weight-bearing surface (Fig 1), such as the plantar aspect of the foot, it can be painful when downward pressure is applied on the foot. Adding a pad to the insole will usually relieve this type of pain.

[FIGURE 1 OMITTED]

Deep Vein Thrombosis

Deep vein thrombosis (DVT) is more common in patients with KTS than in those with normal varicose veins. (20) In our series, 11 (4%) of 252 patients had documented DVT. (5) It is important to diagnose and treat immediately any DVT with anticoagulation or, selectively, with thrombolytics if the DVT involves the large iliofemoral veins. Pain is a usual presentation, in addition to swelling and cyanotic discoloration of the leg.

We recommend that patients with KTS avoid estrogen-containing contraceptives and heed precautionary measures to prevent thrombosis during long periods of immobilization. Whether patients with KTS should receive prophylactic anticoagulation therapy or antiplatelet therapy is controversial. Certainly prophylactic anticoagulation therapy should be considered for patients who have had recurrent DVTs, particularly when complicated by pulmonary embolus. It is unclear whether prophylactic anticoagulation or antiplatelet therapy is effective in preventing superficial thrombophlebitis. Considering that spontaneous bleeding from superficial venular blebs can be problematic, one must consider this when contemplating chronic anticoagulation. Patients with recurrent DVT should be considered for placement of an inferior vena cava filter to prevent major pulmonary embolus.

Intraosseous Vascular Malformations

Rarely, patients with KTS can have intraosseous vascular malformations. (21) Although rare, they usually occur in long bones (Fig 2), but we have reported 1 patient (13) who had multiple osteolytic lesions of the calvarium (Fig 3). These lesions cause intense pain. When they involve long bones, there is an increased risk for fracture. A variety of analgesics can be tried, but in most cases, surgical removal of the malformation may be necessary. If the lesions cannot be removed, then management of the pain can be challenging. Some of these patients may require long-term opiates for pain control.

[FIGURES 2-3 OMITTED]

Calcified or Scarified Vascular Malformations

Calcified vascular malformations can be a source of pain if located around structures that are mobile, such as the ankle joint (Fig 4). We have seen this occur in natural calcification of a vascular malformation. We have also seen it as a result of sclerotherapy of a vascular malformation. If well localized, then surgical removal may relieve this type of pain.

[FIGURE 4 OMITTED]

Arthritis

In a study of 27 patients with purely venous malformations occurring within the extremities, it was found that 81% (13 of 16) of lower limb cases and 36% (4 of 11) of upper limb cases involved arthritis of the knee and elbow joint, respectively. In 7 of the 16 lower limb cases in this study, patients had to undergo surgical treatment for severe functional impairment, which consisted of synovectomy and excision of the venous mass. (22) In our experience, arthritis occurs in a very small number of patients with KTS, but in those patients, it is a major problem. Usually it involves the knee, but we have also treated patients with ankle involvement. MRI of the affected joint will establish the presence of intra-articular vascular malformation. Proliferative vascular synovitis and an associated joint effusion is the usual accompanying findings on MRI.

Destruction of cartilage occurs probably from recurrent hemarthrosis when the vascular malformation is within a joint (Fig 5). Alternatively or in addition, the presence of the vascular malformation may create a chronic synovitis. Patients with this have pain and, as a result, keep the knee flexed, and they can develop a flexion contracture.

[FIGURE 5 OMITTED]

Treatment includes analgesics and maneuvers to prevent the flexion contracture. This may involve physical therapy, passive stretching, and bracing. Synovectomy may be useful but is unproved at this time. If the flexion contracture is severe enough to prevent walking and the leg cannot be straightened, then amputation may be necessary to control the pain and allow the patient to walk (with a prosthesis).

Neuropathic Pain

Neuropathic pain results from damage or dysfunction of neuronal pathways and is a shooting, burning, aching (or a combination) pain that is poorly responsive to conventional analgesics. It often occurs in areas with altered sensation. We have evaluated 4 patients who have KTS with neuropathic pain. Their pain is disabling and associated with hyperesthesia. All 4 patients are adults, and all have KTS involving the leg. Three of the 4 had extensive surgical procedures on the leg, and in 2 of these, the pain occurred after the surgical procedures. We speculate that neuropathic pain can result from damage to nerves at the time of operation. Also, we think that this pain can result from effects of the venous abnormality on the nerve that shares the neurovascular bundle. It may result from direct compression of the nerve and/or abnormal venous pressure of the nutrient vascular system of the nerve.

The management of neuropathic pain is difficult as such pain responds poorly to conventional analgesics and less well to opioids. In the past 30 years, antidepressants and anticonvulsants have been the 2 major classes of drugs used to treat neuropathic pain. (23-25) Their mechanism of action relies on inhibition of excitatory pathways or enhancement of inhibitory pathways. Drugs such as carbamazepine, phenytoin, lamotrigine, and felbamate inhibit the excitatory sodium channels, whereas valproic acid increases the inhibitory pathways of [gamma]-aminobutyric acid. In this manner, the excess firing of neuronal pathways that lead to pain is dampened. The choice of which agent to use is a matter of trial and error as not one has been shown to be more efficacious than another. We tend to introduce 1 agent at a time at a low starting dose, titrate up to desired effect, and if not beneficial after a trial period of 2 to 3 weeks, we substitute another agent. More than 1 drug is sometimes necessary to control the pain. The short-term use of steroids (Prednisone) can also be used for acute neuropathic pain.

DISCUSSION

KTS occurs in 1 of 20 000 to 40 000 live births. The manifestations of KTS are protean and historically has been confused with other overgrowth syndromes such as Proteus syndrome and Parkes Weber syndrome. The absence of clinically significant arteriovenous shunting distinguishes KTS from Parkes Weber syndrome. (26)

The triad of capillary malformations (port wine stain), varicosities or venous malformations, and limb hypertrophy has been found to occur in 98%, 72%, and 67% of patients, respectively, in our series (5) of 252 patients. All 3 features were present in 63% of patients, and 37% had 2 of the 3 features, which illustrates that not all patients with KTS have all 3 features of the triad, and patients can receive a diagnosis of KTS with only 1 or 2 features. The cause of KTS is still unclear. Several theories have been proposed, including (1) Servelle's theory of a primary obstruction of the venous system resulting in venous hypertension and therefore development of abnormal venous pathways and tissue overgrowth; (2) failure of regression of the lateral limb bud vein; and (3) alteration of the tight balance between angiogenesis and vasculogenesis, which is controlled by numerous genes, among other theories. (27-30) KTS is a mixed malformation whereby soft tissue and bony malformation is associated with predominantly venous, lymphatic, and capillary vascular malformations, with involvement of usually 1 of the lower limbs.

Although pain is such a prevalent morbidity factor and affects up to 88% of patients with KTS, the causes of pain have not been well documented up until now. We have observed that there are 9 most common causes of pain in these patients: (1) chronic venous insufficiency, (2) cellulitis, (3) thrombophlebitis, (4) DVT, (5) calcification of vascular malformations, (6) growing pains, (7) intraosseous vascular malformation, (8) arthritis, and (9) neuropathic pain. Common complications that accompany KTS and also may contribute to pain include pregnancy-associated complications, coagulation abnormalities, and the psychological effects of the visible overgrowth.

Perhaps chronic venous insufficiency accentuates and predisposes to the other causes of pain. If that is the case, then controlling the venous insufficiency and improving venous drainage might reduce pain of a variety of causes. Although the true pathophysiology of venous insufficiency is not yet fully understood at this point, mechanisms that incorporate external compression, limb elevation, exercise, and even a pump to improve venous drainage may be beneficial.

Because it is such a rare condition and because of zits protean manifestations, most health care providers are uncomfortable treating patients with KTS. Hence, most patients become frustrated by their inability to find local health care providers who can help them deal with the many complications associated with KTS. For patients in whom pain significantly affects their quality of life, it is important to have local health care providers who can work with the patients on an ongoing basis to manage chronic pain. Because there are numerous causes of pain in KTS, the first step in management is to define the exact cause of the pain. One also must recognize that individual patients may have >1 source of pain, and treatment strategies must be designated to deal with all of the types of pain in an individual patient. A multidisciplinary team that has experience with KTS may best perform the initial evaluation of these patients. However, a local health care provider is best in providing ongoing care. We hope that this review will be useful to achieve this.

REFERENCES

(1.) Meine JG, Schwartz RA, Janniger CK. Klipel Trenaunay Weber syndrome. Pediatr Dermatol. 1997;60:127-132

(2.) You CK, Rees J, Gillis DA, Steeves G. Klippel Trenaunay syndrome: a review. Can J Surg. 1983;26:399-403

(3.) Guidera KJ, Brinker MR, Kousseff BG, et al. Overgrowth management in Klippel-Trenaunay-Weber and Proteus syndromes. J Pediatr Orthop. 1993;13:459-466

(4.) Berry SA, Peterson C, Mize W, et al. Klippel-Trenaunay syndrome. Am J Med Genet. 1998;79:319-326

(5.) Jacob AG, Driscoll DJ, Shaughnessy WJ, Stans AW, Clay RP, Gloviczski P. Klippel Trenaunay syndrome: spectrum and management. Mayo Clin Proc. 1998;73:28-36

(6.) Baskerville PA, Ackroyd JS, Thomas ML, Browse NL. The Klippel Trenaunay syndrome: clinical, radiological and hemodynamic features and management. Br J Surg. 1985;72:232-236

(7.) Telander RL, Kaufman BH, Gloviczki P, Stickler GB, Hollier LH. Prognosis and management of lesions of the trunk in children with Klippel-Trenaunay syndrome. J Pediatr Surg. 1984;19:417-422

(8.) Gloviczki P, Hollier LH, Telander RL, Kaufman B, Bianco AJ, Stickler GB. Surgical implications of Klippel-Trenaunay syndrome. Ann Surg. 1983;197:353-362

(9.) Noel AA, Gloviczki P, Cherry KJ, Rooke TW, Stanson AW, Driscoll DJ. Surgical treatment of venous malformations in Klippel-Trenaunay syndrome. J Vasc Surg. 2000;32:840-847

(10.) Cherry KJ, Gloviczki P, Stanson AW. Persistent sciatic vein: diagnosis and treatment of a rare condition. J Vasc Surg. 1996;23:490-497

(11.) Gloviczki P, Stanson AW, Stickler GB, et al. Klippel-Trenaunay syndrome: the risks and benefits of vascular interventions. Surgery. 1991;110:469-479

(12.) McGrory BJ, Amadio PC, Dobyns JH, Stickler GB, Unni KK. Anomalies of the fingers and toes associated with Klippel-Trenaunay syndrome. J Bone Joint Surg Am. 1991;73:1537-1546

(13.) Sorom A, Driscoll DJ, Stanson AW. Klippel-Trenaunay syndrome: a rare cause of severe headache. Int Angiol. 2002;11:7-8

(14.) Travers JP, Brookes CE, Evans J, et al. Assessment of wall structure and composition of varicose veins with reference to collagen, elastin and smooth muscle content. Eur J Vasc Endovasc Surg. 1996;11:230-237

(15.) Rose SS, Ahmed A. Some thought on the etiology of varicose veins. J Cardiovasc Surg. 1986;27:534-543

(16.) Araki CT, Back TL, Padberg FT, et al. The significance of calf pump function in venous ulceration. J Vasc Surg. 1994;20:872-877

(17.) Labropoulos N, Ginannoukas AD, Nicolaides AN, et al. The role of venous reflux and calf muscle pump function in nonthrombotic chronic venous insufficiency. Correlation with severity of signs and symptoms. Arch Surg. 1996;131:403-406

(18.) Nicolaides AN, Zukowski AJ. The value of dynamic venous pressure measurements. World J Surg. 1986;10:919-924

(19.) Quartey-Papafio CM. Lesson of the week: importance of distinguishing between cellulitis and varicose eczema of the leg. BMJ. 1999;318: 1672-1673

(20.) Fowkes FJ, Price JF, Fowkes FG. Incidence of diagnosed deep vein thrombosis in the general population: systematic review. Eur J Vasc Endovasc Surg. 2003;25:1-5

(21.) Samlaska CP, Gagliardi JA. Diffuse venous malformation with intraosseous involvement. Hawaii Med J. 1994;53:218-221

(22.) Enjolras O, Ciabrini D, Mazoyer E, Laurian C, Herbereteau D. Extensive pure venous malformation in the upper or lower limb: a review of 27 cases. J Am Acad Dermatol. 1997;36:219-225

(23.) McQuay H. Neuropathic pain: evidence matters. Eur Pain. 2002; 6(suppl A):11-18

(24.) Dickenson AH, Matthews EA, Suzuki R. Neurobiology of neuropathic pain: mode of action of anticonvulsants. Eur J Pain. 2002;6(suppl A): 51-60

(25.) Jensen TS. Anticonvulsants in neuropathic pain: rationale and clinical evidence. Eur J Pain. 2002;6(suppl A):61-68

(26.) Biesecker LG, Happle R, Mulliken JB, et al. Proteus syndrome: diagnostic criteria, differential diagnosis, and patient evaluation. Am J Med Genet. 1999;84:389-395

(27.) Tian X, Liu M, Kadaba R, et al. Positional cloning of a novel angiogenic factor gene: VG5Q mutations cause susceptibility to KTS. Nature. 2004; 427:640-645

(28.) Whelan AJ, Watson MS, Porter FD, Steiner RD. Klippel Trenaunay Weber syndrome associated with a 5:11 balanced translocation. Am J Med Genet. 1995;59:492-494

(29.) Ceballos-Quintal JM, Pinto-Escalante D, Castillo-Zapata I. A new case of Klippel-Trenaunay-Weber (KTW) syndrome: evidence of autosomal dominant inheritance. Am J Med Genet. 1996;63:426-427

(30.) Servelle M. Klippel and Trenaunay's syndrome. 768 operated cases. Ann Surg. 1985;201:365-373

Adriana Lee, MD *; David Driscoll, MD * ([double dagger]); Peter Gloviczki, MD ([section]); Ricky Clay, MD ([parallel]); William Shaughnessy, MD ([paragraph]); and Anthony Stans, MD ([paragraph])

From the Departments of * Pediatric and Adolescent Medicine, ([paragraph]) Orthopedic Surgery, ([double dagger]) Divisions of Pediatric Cardiology, ([section]) Vascular and ([parallel]) Plastic Surgery, Mayo Clinic School of Medicine, Gonda Vascular Center, Mayo Clinic and Mayo Foundation, Rochester, Minnesota.

Accepted for publication Aug 11, 2004.

doi:10.1542/peds.2004-0446

No conflict of interest declared.

Reprint requests to (D.D.) Division of Pediatric Cardiology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905

2005-11-29T20:44:00.000-05:00

Agence France Presse English

02-17-2005

Plastic surgeons at work

Plastic surgeons at work. Americans underwent close to 12 million surgical or non-surgical cosmetic procedures in 2004, a rise of 44 percent from the previous year, according to the American Societ for Aesthetic Plastic Surgery.

Americans underwent close to 12 million surgical or non-surgical cosmetic procedures in 2004, a rise of 44 percent from the previous year, with liposuction and botox treatment leading the surge.

In its annual report published Thursday, the American Society for Aesthetic Plastic Surgery (ASAPS) said 90 percent of the procedures were performed on women.

ASAPS president Peter Fodor attributed the jump in cosmetic treatment to increased media attention.

"People have had many more opportunities to see, first hand, what plastic surgery is like and what it can do for others," Fodor said. "That can be a strong incentive for them to seek the same benefits by having cosmetic procedures themselves."

The annual report found that 11.9 million procedures were carried out last year.

Surgical procedures were up 17 percent on 2003, with liposuction leading the treatment table with more than 478,000 operations.

Breast augmentation was the second most popular, followed by eyelid surgery, rhinoplasty (nose jobs) and facelifts.

While breast enlargements among women in general were up 19 percent at more than 334,000, they plunged 63 percent among teenagers to 4,211.

On the non-surgical side, procedures were up 51 percent, with more than 2.8 million people opting for anti-wrinkling botox injections and 1.4 million going in for some laser hair removal.

Although men accounted for only 1.2 million, or 10 percent, of the overall number of procedures, ASAPS said the figure represented an increase of more than 300 percent from 1997.

An ASAPS survey of 1,000 Americans found that 21 percent of men interviewed said they would consider cosmetic surgery -- an increase of 50 percent from 2003.

© Copyright Agence France Presse

2005-11-26T08:06:00.000-05:00

Byline: JANE SIMON

AS Karen Bernard stepped out of the sea, she could feel all the fear and anxiety of the last three years washing off her.

A natural extrovert, she had gone topless on the beach many times before - but this time was different.

In June 2001, at the age of 38, Karen found out she had breast cancer and underwent a double mastectomy and breast reconstruction.

The diagnosis had come just five months after she separated from her husband of 14 years.

But, incredibly, instead of buckling under the stress, Karen describes having cancer as "a great experience".

And to help other women, she kept a photo diary of every stage of her treatment - to the amusement of family and friends who have been ordered to take topless photos of her everywhere from Blenheim Palace to the Grand Canyon.

Now at her home in Hertfordshire, as Karen talks about publishing her photos in a book, it's impossible not to be impressed by the positivity she radiates.

"Breast cancer was obviously a lesson sent for me to learn something from," she says. "Before my operation I asked if there were other women I could meet who'd had reconstructions or any pictures I could see.

"I was told I wouldn't want to see them. But I did. My doctor said other women might not be as relaxed about taking their tops off as I am.

"Since my surgery, I've shown my new breasts to a few women who've just been diagnosed with breast cancer and they say I've taken the fear factor out of it."

October is breast cancer awareness month, but Karen, 41, believes it's not women who need to be made more aware of the disease but doctors.

"I was told twice by the first cancer specialist I saw that I was too young to have breast cancer and too young to have the mammogram I asked for. If I'd listened to him, I could be dead now."

Ten years earlier, Karen's mother had breast cancer and since then Karen checked her breasts regularly. When her symptoms appeared literally overnight, the timing couldn't have been crueller.

"For the first time since my marriage ended I'd had a really blinding night out with friends," Karen recalls. "And then I woke up in the night, stretched, and found the lump in my right breast.

"My GP referred me to a cancer specialist who insisted I was just being over-anxious. He said, 'If you get fed up with the lump and it annoys you, come back in six months' time and I'll whip it out.' Those were his actual words.

"Fortunately for me, my mother made me an appointment to see her specialist at St John and Elizabeth Hospital the very next day. He took a core biopsy on the spot and four days later he confirmed I had breast cancer."

Because Karen had small breasts, there was a risk the cancer had spread to the ducts as well, and she was told a mastectomy was the only option.

"I didn't want to feel lopsided, so I said, 'Fine, I'll have a double mastectomy'. Then I left the room to get my head round it, leaving my mother and the doctor stunned."

Karen is a practising Buddhist and believes that chanting helped her keep a positive attitude. "I'd seen my mother get through cancer and be incredibly brave and that gave me strength. And I knew I had to be strong for my children, who'd been through a lot."

At the time James was 12 and Victoria was 11, and faced the additional worry of knowing that this type of cancer was hereditary.

Because she was young and fit, doctors told Karen she would be an ideal candidate for reconstruction.

"I told my plastic surgeon: 'I'm a single girl - it's very important that I look normal, can you save my nipples?' But they couldn't because the cancer could have gone into them too." The operation lasted seven hours.

"When I came round I remember seeing for the first time that I had a cleavage," Karen recalls. "I thought it must be the morphine.

"I'd also been told that after a mastectomy I wouldn't be able to lift my arms above my head, so I asked for my hairbrush and brushed my hair. I was determined not to be ill.

"Every day I'd get dressed in jeans and a little vest top, put on some make-up and go sit in the hospital garden.

"I'd had implants of silicone and saline and over the next few months they'd inject me with more saline to gradually pump me up through two valves under the skin on each side.

"At first I didn't heal well. My skin went black and there was a chance they'd have to take out the implants.

"But I think I frightened the doctors with how positive I was. Before I was discharged, a nurse asked me if I'd looked at myself yet.

"She took my bandages off and made me look in the mirror. That was the first time it was really scary. I looked like I'd been in a car crash.

"But the best thing was when my friend Mandy came to visit after I'd come out of hospital. I was having _ a bath and warned her it was a bit gory, but she said: 'Oh my god, those are the best boobs I've ever seen!' It was exactly what I needed to hear.

"Since then I've shown them to most people I know and even people I don't.

But there was still the issue of nipples. "At first I was issued with stick-on nipples but they don't stick very well and I was always worried about one falling off. I've since found a wonderful tattoo artist who tattoos my nipples on for me. They keep fading so I've had it done three times, but he refuses to take any money for it."

Karen's lymph nodes weren't affected so she didn't need chemotherapy.

But because the type of cancer both she and her mother suffered was oestrogen receptive, she later had her ovaries removed as a precaution. "I was more angry having my ovaries taken away than my breasts," Karen admits.

"I wondered if anyone would ever see me as a woman again. But they have and I have had boyfriends since then.

"Once when I was seeing someone, I went to my plastic surgeon for my regular saline top-up and told him: 'I've got a big weekend, so I'd really like a good pair.'

"Then I went to Tesco's and as I was leaning over the vegetable counter I knocked this poor woman in the face. She looked stunned being whacked with this great big bosom. So I had to have some saline drained because they were lethal weapons.

"I used to be a 34B and now I'm a 36C. I'm very comfortable with my body so I think that helps other people not be so frightened of it either."

But it wasn't until this August on the Greek island of Zante that Karen felt brave enough to go topless again.

"I was in Greece with girlfriends and I was happy to take off my top while I was sunbathing lying down but I'd put it on to go swimming. Then I realised: I am me and people might look at me and stare, but they might look at me and think, she's got courage. I whipped off my bikini top and swam in the sea for the first time since I got cancer.

"I felt incredibly liberated. It was the end of one chapter and the start of the rest of my life.

"I really believe that cancer was a challenge I had to get over to progress with my life. It made me grow up and realise you have to grab life with both hands.

"My ex-husband, Geoff, and I used to have our own business as mortgage brokers. We're still good friends and continued working together.

"But I realised I didn't want to sit in an office any more, so I qualified to do massage, Reiki and Indian head massage. Now I'd like to offer them in cancer clinics."

And in a fairytale postscript to her story, Karen has fallen in love with a man who lives in France.

"After cancer, I felt pretty emotionless, so to have all these emotions turned on again, to feel this wanted, this loved, after all that's happened is too amazing for words."

To make a donation to Cancerkin, call 020 7830 2323.

j.simon@mirror.co.uk

CAPTION(S):

BLESSING: Aged one with mum and dad; Karen in her garden in 2001 before the diagnosis; Soaking up the sun on a barge in September 2002; Flashing more than a smile, Grand Canyon, April 2002; Confidence in the Caribbean. A holiday in Jamaica, 2003; FACING THINGS: Karen in hospital; FULL OF LIFE: Karen offers a positive message

2005-11-23T22:36:00.000-05:00

The Record (Bergen County, NJ)

05-30-2004

Flaunting those nips and tucks -- PLASTIC SURGERY HAS BECOME MAINSTREAM

By LESLIE KOREN, STAFF WRITER

Date: 05-30-2004, Sunday

Section: LIVING

Edtion: All Editions.=.Sunday

For 10 years, 47-year-old Jane M. watched enviously as other women got their tummies tucked by the plastic surgeon whose Paramus office she manages.

But last June, she finally got her own done (with a little lipo while they were in there), and ever since, the envy has been flying the other way.

"Oh my God, I wish I was you," friend after friend has said.

Goodbye shame, hello scalpel. Plastic surgery is morphing into a mainstream beauty tactic. Going under the knife for a tighter face or slimmer stomach is becoming more about good grooming, sort of like waxed eyebrows and manicured nails, and less about gaudy vanity.

"It's so much more acceptable today - not like years ago, when people were afraid to tell people," said Jane's boss, Paramus plastic surgeon John T. Cozzone. "And it's not just for the wealthy. Everyday normal people are doing it."

And they are doing it before our very eyes. The spring prime-time television schedule was bursting with plastic surgery reality shows spotlighting the transformation of average-looking individuals into "beautiful" people. No matter that it may have involved three, four, or 12 surgical procedures. In almost every case, at least as portrayed by the sheer joy at their "reveal," the ends justified the means.

This is all part of the normalization of a cultural phenomenon, said critic Virginia Blum, author of "Flesh Wounds: The Culture of Plastic Surgery." We are mid-stride in the evolution from outrageous to ordinary.

"There is a feeling that if you can transform yourself, you can have a different life. That's really an American story. And then it gets yoked to consumer culture. Buy this and you will feel better. A better body becomes something you buy," said Blum, who herself had a nose job when she was a teenager.

The new packaged plastic surgery, in which a patient opts for a combination of procedures, "is like buying a car with all the perks. There is nothing left wanting," she said.

Before the Seventies, people who had cosmetic surgery were considered pathological, Blum said. In the Eighties, celebrities who got it done were "outed" in tabloids and risked humiliation. Remember - just a couple of years ago - the tempest over the eye job Greta Van Susteren got before moving to Fox News Channel?

Soon, Blum argued, we will come to a time when it will be like getting braces, and people will wonder why someone didn't get plastic surgery to fix their body.

"With Greta Van Susteren it will be like: 'Why didn't she have a whole lower body lift? She only had her eyelids done?' It will move into a place where we criticize people for not having done more," she said.

Sander Gilman, who has written two books about the history and culture of plastic surgery, traces the growing comfort with plastic surgery to the mid-Nineties, when the Discovery Channel first ran shows depicting patients' experiences.

This season, there were four prominent plastic surgery shows; two - ABC's "Extreme Makeover" and Fox's "The Swan" - were reality shows in which candidates were treated to a variety of services, usually including a large number of surgical procedures. The two contestants on "The Swan" then went on to compete for a spot in the show's own beauty pageant, causing a stir among critics.

MTV's "I Want a Famous Face" was a documentary series featuring young Americans who wanted to look more like a certain celebrity and often used implants, lifts, and a host of other surgical techniques to make their dream come true. FX's "Nip/Tuck," a scripted drama, begins its second season June 22. "The Swan II" debuts in November.

Plastic surgeons say the programs have swelled their waiting rooms with new patients at a time when plastic surgery was already on the rise. In 2003, doctors performed more than 8.7 million cosmetic surgeries, up 32 percent over 2002.

"Especially this 'Extreme Makeover' has increased the volume of people who come into the office," Cozzone said. "It has had a positive effect."

Unlike the makeover shows, where the transformation can be dramatic, the vast majority of clients are not looking for wholesale makeovers, said New York plastic surgeon Mauro Romita. Rather they want smaller fixes, for concerns such as a bump in their nose or too many wrinkles, he said.

Still, the American Society of Plastic Surgeons (ASPS) was thrilled with "Extreme Makeover."

"Out of it came many good lessons," said Montclair plastic surgeon Allen Rosen, an ASPS spokesman. "They were taking patients with real cosmetic concerns and seeing that at the end of the day, they were feeling good about themselves."

And it just happened to have altered a lot of people's minds about plastic surgery, including that of one of the show's executive producers, Lou Gorfain. Before viewing an episode, he considered plastic surgery "a vanity thing" and the concept for the program "very exploitive."

"I thought, 'What has reality TV come to: carving up people for the amusement of millions?'-" he said.

But when he saw the impact of the surgeries, his impressions shifted.

"These were people whose lives were deeply, deeply affected by their appearances. The changes they made were more than cosmetic. They made a holistic impression," he said.

MTV's "I Want a Famous Face" was more disturbing, perhaps because it documented an extreme segment of our society. MTV did not pay for the surgeries, it simply followed people who were willing to pay a high price, in both pain and money, for their new look.

Kate Winslet said she wept after watching a show in which a fan underwent extensive surgery to look more like her. In another episode, a blonde wanted the bust of Pamela Anderson so she could be a Playboy Playmate. A third spotlighted two brothers' efforts to resemble Brad Pitt.

Rosen said a proper surgeon's job is not to make others look like someone else, but to enhance and "bring into balance" the individual. However, the idea for the show came after following around young plastic surgery patients, most of whom brought in photos of celebrities, said co-creator and producer Marshall Eisen.

"We're documenting what's really happening out there. Part of what's shocking to some people who see this is finding out how prevalent it is out there," he said. Rosen argues that when patients bring in a photo to his office, which they do frequently, he uses it to help identify what they desire in a feature - sculpted and balanced or chiseled and strong - as opposed to trying to replicate someone else's nose on another individual's face.

But Eisen was not surprised to find so many people who wanted to look more like a celebrity. We live in a culture with an established beauty ideal, so it's a natural outgrowth, he said.

Nely Galán, creator of "The Swan," loves the idea that plastic surgery will soon be considered as normal to Americans as apple pie, as it is in much of the Latin world.

"To say you have plastic surgery is a status symbol. Beauty is very important to us," said the Cuban-American, who hails from Teaneck.

American women feel bad about themselves because they can't measure up to a celebrity beauty that exists largely as a result of the plastic surgery most of the stars are getting done, she said. As Galán sees it, the problem is not that people are getting the work done, but that no one is admitting it.

Perhaps, she said, if the media were more honest with their images of women, people would feel less need to achieve the same level of unattainable perfection.

"I hope that within the next five years, it will be very cool for actresses to admit what they've gotten done instead of all trying to hide it and make people feel bad and think that they are somehow genetically better," she said.

Studies three years after cosmetic surgeries show that patients remain satisfied, Gilman said.

"How many people, after three years, are still satisfied with their cars?" he asked.

Blum, however, is less certain.

"I'm not anti-plastic surgery. But I think it is not making people as happy as it promises to," she said.

Less invasive procedures and more outpatient work are making the procedures easier to obtain, another factor contributing to the increasingly blasé attitude toward the surgery.

Romita has an operating room in his Fifth Avenue office, where he can perform a short-scar face-lift, rhinoplasty, and breast augmentation, among other procedures. The shorter surgeries, which require less anesthesia, are more appealing to people who don't want to stay in a hospital and don't want to be out of commission for long.

"Now it's like taking a gallbladder out," Romita said. "Safer, faster healing, and the results are better."

Traditional plastic surgery costs have held steady for the past five years, but now the outpatient procedures are cutting them significantly. Anesthesia is 20 percent cheaper, and the facility costs are about 60 percent less. Where a hospital face-lift may cost between $4,600 and $5,000, a similar procedure in Romita's office might be $3,000, he said. The same is true for eyelids and noses.

Still, there are many people like Jane M., the doctor's office manager, and an Oradell real estate broker interviewed for this story, who are very happy with the outcome of their surgery but remain reluctant to be quoted by full name.

"I'm absolutely thrilled. It feels good," said the 52-year-old real estate agent, who got her eyes done and plans to get a face-lift in a few years.

"I don't think I would say too much to too many people," she said. "There's bound to be a story, some horror story, and that's not what you need to hear."

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E-mail: koren@northjersey.com

Illustrations/Photos: * * *

Keywords: LIFESTYLE, SURGERY

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