ear plastic surgery

2006-01-19T14:30:00.000-05:00

Colorado Springs, Colo. -- Facelift patients with hollow-looking eyes have new hope in the form of the septal reset procedure. Part of the composite facelift approach pioneered by Sam T. Hamra, M.D., F.A.C.S., the procedure picks up where previous advances left off by recruiting fat from the subseptal space.

"A young-looking lower eye and cheek is convex;' says Dr. Hamra, assistant clinical professor of plastic surgery, University of Texas Southwestern Medical Center. "The older eye, by age 40, is concave. And the vertical height of the lower eyelid--from the eyelid down to the cheek--widens as you get older. You want to make it more narrow and youthful by pushing tissues up toward the eye, not toward the ear."

Removing lower eyelid fat only exacerbates the hollowed-out appearance. However, while refining his composite facelift procedure in the early 1990s, Dr. Hamra built upon the knowledge that one can use the medial lower lid fat pad to improve deep nasojugal grooves. (1) As in Dr. Loeb's procedure, Dr. Hamra continued to remove patients' middle and lateral fat pads when they were excessive. Unlike this procedure, however, Dr. Hamra's involves repositioning the entire orbicularis oculi muscle in order to shorten the vertical height of the lower eyelid.

By 1993, unsatisfied with results from using only the medial fat pad, Dr. Hamra decided to preserve and use all of the orbital fat. The result was the arcus marginalis release with transposition of fat. (2) He continued to develop the technique, which has resulted in the septum orbitale reset or "septal reset". (3) It allows cosmetic surgeons to even better camouflage what he calls the skeletonization of the periorbit by covering the orbital rim with orbital fat along with the septum orbitale.

With this approach, Dr. Hamra noticed marked improvement in his results because it allows the repositioned orbicularis to rest on a firm undersurface of septum, not on the concavity created by fat removal (or the softness of fat only).

Before operating, one must decide whether fat must be resected or not, and if so, how much, based on each individual patient's anatomy. Once this determination is made, the procedure itself involves several steps.

The procedure

First, Dr. Hamra develops a zygomaticus-orbicularis flap (2) to mobilize the midface. Then, he performs an arcus marginalis release.

To do this procedure, he tells Cosmetic Surgery Times, "You release the arcus marginalis and determine how much fat should be preserved or removed."

More precisely, the arcus release requires incising the junction of the septum orbitale and the periosteum of the inferior orbital rim (the arcus marginalis). Dr. Hamra accomplishes this procedure with cutting cautery (and no local anesthetic injected in this area), after he's done a zygorbicular dissection. The septal reset follows the transcanthal canthopexry.

To perform the septal reset, Dr. Hamra uses 5-0 Vicryl sutures, usually eight to 12 of them to create a smooth transition. Tension hereby created must be sufficient to forma firm undersurface upon which the orbicularis will rest.

Dr. Hamra originally used 4-0 nylon for the transcanthal canthopexy. Later he experimented with nonpermanent suture materials including chromic catgut in an effort to shorten patients' recovery time. Patients recovered no more quickly with these methods, however. In addition, he learned that the stronger the tension he exerted on the superior-medial vector suspension of the cheek flap, the more effectively he could reposition the zygorbicular flap. For these reasons, he now believes that the permanent suture ensures more stable support for the reconstructed eye-cheek area.

If he's performing the reset as part of a composite facelift, Dr. Hamra ultimately advances and secures the zygorbicular flap to the orbital rim before closing facelift and forehead dissections. The tension of this superior medial vector must be maximal, he says. That's because it must overcome and balance the lateral tension of the superficial musculoaponeurotic system fixation. The last step of the reset procedure is trimming skin, if needed.

Unique feature

The unique feature of the composite facelift, Dr. Hamra concludes, is a superior-medial vector of the repositioned cheek and eyelid complex. Other techniques employ vertical or superior-lateral vectors. Of the three vectors, he says only the superior medial and vertical techniques will shorten the vertical height of the lower eyelid.

Dr. Hamra says the composite facelift with the septal reset will create a more attractive and harmonious appearance than conventional procedures. More importantly, it will prevent the unwanted stigma of hollow eyes and the lateral sweep. It is also the only published technique that can correct these signs of previous facelift surgery.

Disclosure: Dr Hamra possesses no financial interests related to products mentioned in this article.

For more information:

(1) Loeb, R. (Ed) Aesthetic Surgery of the Eye-lids. New York: Sprinqer-Verlag. 1989.

(2) Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 96: 54. 1995.

(3) Hamra ST. The Role of the Septal Reset In Creating a Youthful Eyelid-Cheek Complex In Facial Rejuvination. Plast Reconstr Surg 113 (7): 2124-2141. June 2004.

(4) Hamra ST. The zygorbicular dissection in composite rhytidectomy. Plast Reconstr Surg 102: 5. 1998.

2006-01-18T07:30:00.000-05:00

2006-01-17T06:08:00.000-05:00

International Herald Tribune

02-23-2005

A competitive swimmer since she was 7, Alex Glashow of Barrington, Rhode Island, logged 8,000 yards a day in the pool, until her arms ached. She learned to dislocate one shoulder intentionally to ease the pain in the water, but after shoulder surgery and a year of physical therapy, Glashow quit competitive swimming when she was 15.Jeret Adair, a top young pitching prospect from Atlanta who started 64 games in one summer for his traveling baseball team, last year had ''Tommy John surgery,'' an elbow reconstruction once reserved for aging major leaguers.Ana Sani of Scarsdale, New York, a 13-year-old budding soccer star, practiced daily until she tore the anterior cruciate ligament in her knee.Many U.S. doctors in pediatric sports medicine say it is as if they have happened upon a new childhood disease, and the cause is the overaggressive culture of organized youth sports.''They are overuse injuries pure and simple,'' said Dr. James Andrews, a nationally prominent sports orthopedist. ''You get a kid on the operating table, and you say to yourself, 'It's impossible for a 13-year-old to have this kind of wear and tear.' We've got an epidemic going on.''Typical injuries range from stress fractures, growth plate disorders, cracked kneecaps and frayed heel tendons to a back condition brought on by excessive flexing that causes one vertebra to slip forward over another. Most are injuries that once were seen only in adults.Dr. Lyle Micheli, a pioneer in the field of treating youth sports injuries and the director of the sports medicine division at Boston Children's Hospital, said that 25 years ago, only 10 percent of the patients he treated came to him for injuries caused by overuse.Back then, most childhood injuries were fractures or sprains. Micheli said overuse injuries now represented 70 percent of the cases he saw.In interviews with more than two dozen sports medicine doctors and researchers, one factor was repeatedly cited as the prime cause for the outbreak in overuse injuries among young athletes: specialization in one sport at an early age and the year-round, almost manic training for it that often follows.Communist countries, such as the former East Germany and nowadays China, have been notorious for pressure and training regiments on their teenage athletes. But the stress and its effect on young Americans is not state-sponsored.''It's not enough that they play on a school team, two travel teams and go to four camps for their sport in the summer,'' said Dr. Eric Small, who has a family sports-medicine practice in Westchester County, New York. ''They have private instructors for that one sport that they see twice a week. Then their parents get them out to practice in the backyard at night.''Dr. Angela Smith, an orthopedic surgeon at the Children's Hospital of Philadelphia, said parents in virtually every sport were pushing their children to excess in pursuit of college or university scholarships or the dream of a professional sports career.''The volume of training has increased beyond the maturing young body's ability to handle it,'' she said.Doctors lament the loss of what has become a cultural artifact: the playground athlete. Two decades ago, sports for children were often unorganized, with pickup games common in schoolyards and community parks.''Children might have played baseball, basketball and football all in the same day,'' Micheli said. ''This was good for their bodies, which developed in balance. Now young athletes play sports supervised by adults who have them doing the same techniques, the same drills, over and over and over.''By playing one sport year-round, there is no rest and recovery for the overused parts of their body,'' Micheli said. ''Parents think they are maximizing their child's chances by concentrating on one sport. The results are often not what they expected.''In his office in Birmingham, Alabama, Andrews hands parents of new patients a piece of chalk and points to a blackboard in the corner.''I say, 'Write down when your child started playing his sport, how many teams he's played for, what camps he went to, for how many years, what private instructors he's seen, what championships he won, what his stats were, all that stuff,''' Andrews said. ''Then I walk out of the room. I come back in and they've filled up the blackboard. They're proud.''And I say: 'You all know why he's here seeing me?' And I point to the blackboard. That's when the light bulb goes off.''But according to several pediatric sports-medicine specialists, not all parents ã and they come from all economic classes ã see the light so clearly. It is not uncommon for the damage done by an overuse injury to be irrevocable, and the doctor's advice is to quit the sport.''That's usually not received too well,'' said Dr. Michael Busch, an Atlanta orthopedic surgeon. ''The parents will ask if there isn't some kind of surgery that can be done so their child can keep doing the things that brought this injury on in the first place. I explain that an operation might be necessary just to alleviate the pain and to set a course for normal everyday use again. ''To tell you the truth, the kids usually take it better than the parents. Many kids are relieved. They can be kids again.''Doctors are also seeing what could be called the Curt Schilling effect in their examining rooms. Schilling was the Boston Red Sox pitcher who underwent a radical medical procedure ã a ruptured tendon sheath in his ankle was sutured in place ã so he could pitch in postseason games last year.''I recently had a mother ask me if there isn't some kind of shot or fix-it procedure I could do for her 11-year-old daughter's ankle so she could be ready for an upcoming regional competition,'' Smith, the Philadelphia orthopedist, said. ''I told her that if it were the Olympic Games coming up, perhaps we could treat this situation differently. But as far as I understood, her upcoming competition wasn't the Olympics.''At this point, the daughter is giggling, but the parent is in the corner crying. I said: 'This isn't Curt Schilling in the World Series. It's not worth not being able to run anymore for a plastic gold-plated medal.'''The doctors who treat young athletes said they were proponents of youth sports, which they said were vital to the health of American children.Participation in sports should be encouraged, the doctors said, but with certain precautions.''I agree there are more overuse injuries but I am still more worried about the high rate of inactivity and obesity in children,'' said Dr. William Roberts, president of the American College of Sports Medicine. ''We need more kids to do a lot more and a few kids to do a little less.''It's also true that not all young athletes break down from overtraining even after years of rigorous workouts. But doctors warn that many young athletes will not complain about pain from sports because they believe it is just soreness, or part of the price for overachieving.''My arm hurt for years, but I never went to the doctor,'' said Adair, 16, the pitcher from Atlanta who underwent the surgery named for John, the Major League Baseball pitcher on whom it was first performed 30 years ago. The surgery involves removing a healthy tendon from one arm and inserting it into the other. Adair had Tommy John surgery last year after the ulnar collateral ligament in his right elbow snapped in two as he was delivering a pitch. ''You know, like they say, you play with pain,'' he said. ''If you're a good pitcher on a team of 14- or 15-year-olds, you're going to be throwing too much. Everybody wants to throw their ace out there.'' He was one of 51 high school pitchers upon whom Andrews performed elbow reconstructive surgery last year, a tenfold increase from a decade ago.One approach to limiting overuse injuries involves training that is specially designed to prevent injuries.Vinny Sullivan, a certified strength and conditioning coach and director of sports performance at Forme Health and Fitness in Scarsdale, said he saw more than 300 young athletes a week in a program designed to reduce overuse injuries. Sullivan has his athletes do exercises to correct muscle imbalances brought on by overtraining in a single sport. He works on their flexibility and balance and their running and jumping biomechanics.Of special focus is teaching young athletes how to decelerate correctly, because many knee injuries result from a sudden stop or change of direction.Among Sullivan's pupils is Sani, the soccer player in Scarsdale, who came for help as a 13-year-old after tearing the anterior cruciate ligament in her left knee. The injury occurred without contact from another player as she was running down the field. She had recently stopped playing other sports to concentrate on her soccer.''Ana is a phenomenal soccer player, but her hamstring muscles were much weaker than the rest of her leg structure,'' Sullivan said. ''Her body hadn't developed anything but the muscles to play soccer.''After a 10-month rehabilitation, she returned to playing soccer ã on three teams at the same time ã and she has just completed her first season at Williams College in Williamstown, Massachusetts. She recently tore the meniscus cartilage ã which helps distribute body weight evenly ã in the same knee she hurt when she was 13.''I don't know if it's a coincidence or not,'' said her mother, Ana Cristina Sani, ''but she hadn't been in her injury prevention program while at college, and that's when she hurt her knee again.'' Micheli of Boston Children's Hospital and many of his colleagues said they believe that better coaching would help reduce overuse injuries among children.''The coaches are volunteers and mean well, but they are not trained,'' Micheli said. ''And every five years, a new batch comes along, and the problems go on unabated. We are vigorously promoting mandatory coaching certification programs where youth coaches can get the education they need to protect the children.''I think town leaders will eventually say to soccer leagues: 'We'll give you the access to our fields, but we want certified coaches.'''Andrews advocates a laundry list of changes. It begins with stopping year-round play in one sport. ''At least three months off,'' he said. For baseball and softball pitchers, he would also ban the radar gun, used to measure a pitcher's speed.''That thing has wrecked more arms,'' he said. ''I'm sick of seeing these kids being torn apart.''Next month, a public service campaign designed to educate young athletes, their parents and coaches about overuse injuries will be launched through a partnership of the American Academy of Orthopedic Surgeons and the National Athletic Trainers' Association. The campaign includes a poster that shows a youth baseball team celebrating after a game with the headline: ''What will they have longer, their trophies or their injuries?''Alex Glashow still goes to the pool, helping out as a lifeguard.''I can stay involved in other ways,'' she said. She tried diving, but that bothered her shoulder, too. She has recently devoted more time to another sport, skiing.Jeret Adair is tossing a baseball again and is hopeful about returning to pitching ã with a strictly enforced pitch count ã by this summer. He wants to pitch in college.''I'm the living example of someone who did too much,'' Jeret said. ''I would tell young kids coming up now, 'Don't be such a hero. Take a rest.'''I look back now at all those games I won when I was 14 or 15. They don't mean so much anymore. They weren't worth it.''***Bruce Weber contributed reporting to this article.

© 2005 Copyright International Herald Tribune. http://www.iht.com

2006-01-17T06:05:00.000-05:00

2006-01-15T14:26:00.000-05:00

Cleveland Jewish News

05-13-2005

The latest trends in plastic surgery involve minimally invasive techniques,

improving safety, and preservation of function.

Rhinoplasty. Modern techniques in rhinoplasty (nose reshaping) reflect the

overall evolution of plastic surgery. Contemporary techniques strive to

preserve individual familial and ethnic characteristics so that the nose

looks refined, natural, beautiful, not artificial. The function of the nose

as an airway is also addressed with adjunctive procedures that correct

internal blockage, so that breathing is improved by surgery.

Facelift. The traditional facelift remains useful and powerful, but less

invasive procedures like the midface lift (elevation of the cheeks and

jowls), endoscopic brow lift (using telescopes through small incisions), or

neck lift may be used instead of, or in addition to, a facelift in

appropriately selected patients. The so-called "one-hour" or internal

suture lifts have not yet gained general acceptance because results seem

temporary. Nonsurgical enhancements can also complement the facelift.

Treatment is tailored to the patient's needs, so that natural, lasting

improvement can be achieved.

Laser resurfacing and nonsurgical techniques. The newest additions are

nonsurgical enhancements, like Botox®, Hylaform®, and Retin-A®. These

modalities can eliminate the need for surgical intervention in some

patients or complement surgery in others. Fillers are injected into

wrinkles to restore thickness to the skin, partially erasing the wrinkles.

Botox® is selectively injected into specific facial muscles to paralyze

them so that they can't form frown lines. Retin-A® is applied topically; it

increases skin cell turnover, thereby reversing sun-damage and diminishing

wrinkles. Laser resurfacing treats fine wrinkles and color irregularities

in the skin. The popularity of these procedures has validated their

usefulness.

Liposuction and tummy tuck. The basic technique for liposuction remains

unchanged: suction fat through limited incisions. The tumescent technique

has been popular for several years; it involves injecting a high volume of

dilute anesthetic solution to minimize pain and blood loss. Because it is

safe and effective, the tumescent technique is considered the standard for

most liposuction cases.

Ultrasonic liposuction uses an internal probe or an external handpiece to

administer sound waves to the fat cells, theoretically to help break them

up and facilitate their removal. This was very popular several years ago.

But further study suggests that it offers little benefit over conventional

liposuction and adds some risks, so it is less commonly used. It remains

useful for certain cases, like gynecomastia (male breast) correction.

Abdominoplasty (tummy tuck) involves removal of excess belly skin and

tightening of the underlying muscle layers to reshape the belly and

waistline. This is one of the most effective and popular plastic surgery

procedures. It is often combined with liposuction.

Breast augmentation. Current trends in breast augmentation include using

minimal (small) incisions, smooth-shelled implants, and placement under the

pectoralis (chest) muscle, to give a more natural, longer-lasting result

than when placed on top of the muscle. The under-the-muscle approach has

been used for years; but an accumulating body of evidence suggests it has

significant advantages long term.

The Food and Drug Administration is currently evaluating the safety of

silicone gel implants, but advisory panels have suggested limited approval.

Currently they can be used for reconstruction when patients are enrolled in

experimental protocols. The evidence that silicone gel causes medical

complications is tenuous, but saline (salt water) filled implants are

versatile and safe.

In medicine, new is often better. However, new can also mean unproven,

untested. When new trends are supported by experimental studies and the

collective experience of national medical societies, they can be taken

seriously. Deciding whether to try a new therapy is like choosing a medical

specialist: The first task is to gather information.

For cosmetic surgery, make sure the physician is certified by the American

Board of Plastic Surgery and is a member of the American Society of Plastic

Surgeons. Qualified physicians may be certified by other specialty boards,

but the patient has a right to know exactly what kind of training the

physician has in cosmetic procedures; a weekend course in liposuction is

not enough.

--Steven A. Goldman, M.D.

Interim chief of plastic surgery

University Hospitals of Cleveland Case School of Medicine

Article copyright the Cleveland Jewish News.

2006-01-11T08:11:00.000-05:00

The receding hairline caused by a coronal or endoscopic browlift might not be so obvious after a primary facelift, but the inching up of the hairline after subsequent touch-ups can result in a significant deformity.

A surgically elevated hair line is a tell-tale sign of cosmetic surgery. For the individual attempting not to broadcast the fact that surgery is partly responsible for his or her good looks, this can be a problem.

The open pre-hairline approach is one solution that helps surgeons avoid significant hairline changes.

E. Gaylon McCollough, M.D., a facial plastic surgeon in Gulf Shores, Ala., has used all the available techniques for lifting the drooping tissues of the forehead and eyebrows.

The founder of the McCollough Plastic Surgery Clinic and the McCollough Institute for Appearance and Health, says cosmetic surgeons tended to go the traditional route with the coronal forehead lift until about 12 to 15 years ago. "Then, the endoscope came along," he tells Cosmetic Surgery Times. "We were all enamored by it and many of us performed the endoscopic forehead lift. What became obvious was that with both the coronal and endoscopic forehead lifts, the hairline was severely elevated. So, I began looking at the alternatives."

While the direct browlift, during which surgeons make the incision just above the brow hairs, and the mid-forehead lift, where surgeons make an incision in the horizontal wrinkle line, are good operations in the right patient, and do not raise the hairline, both result in scars on the exposed forehead. In a small percentage of cases the scars are visible on close observation.

Best of all worlds

For nearly three decades in practice, Dr. McCollough has refined his approach by assessing the pros and cons of the many different options for surgical browlifting. He determined that one way to avoid raising the hairline and visible scarring is to make an incision at the hairline.

"In many of these cases, using this approach, you can actually lower the hairline if the patient already has one that is elevated," he explains. "You get closer to the eyebrow, so you can get a better browlift."

He made note when hair transplant surgeons began to advocate the trichophytic incision with scalp flap techniques, meaning the incision is made at the hairline and is cut across the hair follicles, rather than parallel to the follicles as recommended when the incision is made within the hairline.

"You undercut the flap edges and lay the skin over the beveled cut on the scalp incision edges, and the hair grows right through the scar," Dr. McCollough says. "What happens is that you get the best of all worlds--you do not raise the hairline (you might lower it) and providing you close the incision under magnification, you get a very acceptable scar, which is camouflaged by the hair growth."

The technique

The incision for the forehead portion of the facelift follows the patient's natural hairline.

"If the hairline is irregular, the incision is irregular," Dr. McCollough says. "And it is made in the manner so that one cuts tangentially across the hair follicles. As one gets to the lateral aspect of the forehead hairline, the incision then trails behind the temple tuft of hair and extends straight down inferiorly, stopping about 3 cm above the ear.

Once Dr. McCollough has made the incision, he retracts the flap and dissects down to the supraorbital rim. He frees the tissues from the supraorbital rim laterally and in the midline and flees the tissues into the glabella. He preserves the supraorbital and supratrochlear vessels and nerves. In many cases, he excises the corrugator muscles.

Dr. McCollough lifts the forehead skin superiorly and depresses the scalp inferiorly until the two overlap. He then removes the overlapping tissues.

"The key to getting the best scar is: on the flap side of the forehead skin the incision is beveled in exactly the same plane on the forehead flap side as it was on the scalp side so that one ends up with a 45-degree angle cut. The forehead skin laps over the cut edges of the scalp skin and, when that occurs, hair follicles grow right through the flap and scar" he says.

Dr. McCollough closes the incisions in the hair-bearing areas with stainless steel staples and places a small number of staples in the skin of the forehead before, running 5-0 plain catgut suture to further approximate the skin edges.

For best results, the closure, he explains, must be done under magnification, so that there is absolute apposition of the skin edges.

"The closure is key to getting a good scar--an acceptable scar. That is why we prefer and strongly recommend that others use magnification during the closure," Dr. McCollough says.

After-care

He puts a pressure dressing over the area to prevent bleeding and hematoma formation, and asks that the patient bathe the incision lines with hydrogen peroxide (if the patient has blonde hair) or with witch hazel (for darker-haired patients) about six times a day.

"If one is going to use absorbable sutures of the skin it is very important that you keep those sutures soft and moist and do not allow them to dry," he cautions.

Cheek lifts

Surgeons performing cheeklifts traditionally make the incision right in front of the ear, extending it straight up from the top of the ear and joining the incision from the forehead lift. "If you elevate the temple with that approach, the temple hairline goes up and back, as well" Dr. McCollough says.

"If a patient has a great deal of sagging, oftentimes that temple tuft of hair can be lifted an inch or two. Not only is that a problem in the primary lift, but it becomes a severe problem with subsequent lifting, where the temple hairline continues to elevate, creating a large non-hair-bearing area just above the ear."

The way to avoid that problem, according to Dr. McCollough, is to make the incision at the top of the ear and take it directly forward to the front edge of the hairline. Surgeons should do everything else in the traditional pretrichael, trichophitic fashion: They would cut across the hair follide then lay the flap over it and close it right under magnification.

"In the temporal area, too, the hair grows right under that scar and keeps the hairline in a normal position," he says. "You do exactly the same thing behind the ear. If the incision behind the ear is taken up into the hairline and you remove an inch or two of loose skin there, the hairline goes up an inch or two. The way to avoid that is to make the incision at the edge of the hairline, the pretrichael. If it is made in the manner where you cut across the hair follicles, which is what the trichophytic approach is, you leave the hairline where it ought to be and the hair growing through the scar helps camouflage it."

Other procedures

Dr. McCollough uses the open pre-hairline approach in most cases, but continues to rely on the other techniques from time to time. lust recently, he did the classic coronal forehead lift on a woman who had a very low hairline.

The open pre-hairline approach is catching on, according to Dr. McCollough.

"Everything in plastic surgery is an exchange. You trade one thing for another," he says. "In facelifting, the exchange is scars for loose, sagging skin. The challenge for the surgeon is to obtain the best surgical result with the least distortion of normal structures, including the hairline. The pretrichael, trichophitic approach to facelifting achieves this goal. Every time I go to a meeting and present this, I have more and more colleagues coming up to me and saying they have tried and like the technique. It is gaining acceptance all around the world."

2006-01-03T22:55:00.000-05:00

New York -- In patients with actinic keratoses (AK) of the scalp, treating the surrounding skin will often evoke subclinical lesions that will respond to treatment, according to Deborah F. MacFarlane, M.D., M.P.H.

Dr. MacFarlane, associate professor of dermatology and plastic surgery, M.D., Anderson Cancer Center, Houston, discussed the emerging concept of field cancerization and therapy in an update on non-melanoma tumors of the scalp at an American Academy of Dermatology (AAD) meeting last year.

Photodynamic therapy

In addition, she discussed several other topics of increasing interest in primary scalp tumors, including photodynamic therapy and lymphoscintigraphy for determining lymphatic drainage patterns in the head and neck.

She also described the contributions of Mohs micrographic surgery.

"For scalp tumors, this is still the gold standard," she says.

Field cancerization

In patients with significant amounts of photodamage and clinically evident AKs, the surrounding skin contains expanded clones of transformed dysplastic cells and subclinical AKs. This is referred to as field cancerization. Such subclinical lesions may regress, remain stable or progress to AKs.

"We find that treatment with topical medications such as imiquimod (Aldara, 3M Pharmaceuticals) will often cause these subclinical lesions to become inflamed, clinically apparent and respond to treatment," Dr. MacFarlane says. "This is field therapy."

Dr. MacFarlane is now using combination treatments in such patients to help prevent progression from AK to in situ squamous cell carcinoma (SCC) to SCC. The combinations include a destructive treatment, such as cryotherapy, followed by a field therapy, such as imiquimod.

"Having patients use self-applied field therapy allows them to participate in their own cancer prevention treatment," Dr. MacFarlane explains.

Photodynamic treatment

Dr. MacFarlane predicts interest in photodynamic therapy will grow.

Photodynamic therapy with topically applied ALA is especially good for multiple nonhyperkeratotic AKs, Bowen's disease and superficial basal cell carcinomas (BCCs).

"Essentially, this is the action of a photosensitizing drug by visible light to produce reactive oxygen species within target cells, resulting in their destruction," Dr. MacFarlane says.

Preliminary work indicates that topical ALA accumulates in sebaceous glands and hair follicles, suggesting it may also be useful in the treatment of hair removal, she adds.

On the "cutting edge" for invasive scalp tumors is lymphoscintigraphy. A radioactive tracer is injected intradermally around the cancer site, and a gamma camera takes images until the sentinel nodes are visualized. Intraoperatively, methylene blue dye is injected into the margin of the lesion, and a neoprobe is used to identify radioactive nodes, which often take up the methylene blue.

Suspect lymph nodes are then removed and sent for cytology.

"As lymphatic drainage in the head and neck is often unpredictable, this technique is useful," Dr. MacFarlane says.

RELATED ARTICLE: Primary scalp tumors: clinical tips.

Dermatologic cancer specialist Deborah F. MacFarlane, M.D., M.P.H., provides clinical tips for successful identification of primary scalp tumors. Here, Dermatology Times provides a brief overview of her recommendations:

* When examining the scalp, remove all hairpieces, hair ornaments, etc.

* Be alert to a variety of clinical presentations, such as the psoriatic or seborrheic plaque that does not respond to conventional treatment, or the area of erythema which recurs around a lesion treated with cryotherapy or electrodessication and curettage.

* Check the postauricular area, especially in men.

* Remember that black patients can develop scalp tumors, too.

* Remember that non-melanoma skin cancers have been reported in nevus sebaceous of Jadassohn. More recently, a case of melanoma has been reported with this entity (Abe S et al Br J Plast Surg. 2003 Mar;56(2):171-173).

* Be aware that immunocompromised patients are especially susceptible to having AKs progress quickly to invasive cancers.

* Examine the scalp especially closely in women with thinning hair. "In fact, the appearance of skin cancers in patients with thinning hair questions the theory that skin cancers reflect sun damage from exposure in the first 20 years of life," Dr. MacFarlane says.

2005-12-31T16:29:00.000-05:00

PEACHTREE CITY, Ga., Sep 21, 2005 (U.S. Newswire via COMTEX) -- Peachtree City, Ga., resident and plane crash survivor Matthew Warmerdam is being honored with the Patients of Courage: Triumph Over Adversity award from the American Society of Plastic Surgeons (ASPS) at its Plastic Surgery 2004 scientific meeting in Chicago, Ill. Warmerdam is being recognized as an inspirational role model for others facing physical trauma.

Just five months out of flight school, Warmerdam was copilot on a commercial jet that crashed outside of Atlanta, Ga. after a propeller blade broke off and jammed into the engine. Warmerdam suffered life-threatening injuries, including second-, third- and fourth-degree burns on 55 percent of his body, requiring the partial amputation of his fingers. Initially, plastic surgeons at Erlanger Medical Center in Chattanooga, Tenn. performed 12 major reconstructive surgeries to save his life, including a tracheotomy, burn care operations, skin grafts and hand surgeries.

In spite of his injuries, Warmerdam was determined to fly again. After his initial care, Warmerdam had numerous secondary reconstructive procedures to restore mobility in his arms and hands. With his wife's support and five years of physical therapy, he learned how to fly again with reconstructed hands. Warmerdam fulfilled his dream and returned to the sky.

"It takes a highly motivated patient to tackle the obstacles facing most reconstructive patients," said ASPS President Scott Spear, MD. "The Patients of Courage stories are wonderful examples of how dedicated surgeons, by virtue of hard work and modern techniques, help patients conquer very difficult and challenging times in their life."

"Flying is what I wanted to do since I was a kid," said Warmerdam. "I wasn't going to let a bad turn of fate keep me from doing what I wanted to do. Even though I left on terms other than my own, I wasn't going to let that stop me from pursuing my dream."

"Matt has been a great inspiration to me. He refused to give up when he was told his goal to fly again was near impossible," stated Louis Carter, MD, of Chattanooga, Tenn. "Matt has taught me the lasting value of perseverance and endurance, the power of family and the importance of being thankful for each and every day of our lives."

For referrals to ASPS Member Surgeons certified by the American Board of Plastic Surgery, call 888-4-PLASTIC (475-2784) or visit http://www.plasticsurgery.org to learn more about cosmetic and reconstructive plastic surgery.

The American Society of Plastic Surgeons is the largest organization of board-certified plastic surgeons in the world. With more than 6,000 members, the society is recognized as a leading authority and information source on cosmetic and reconstructive plastic surgery. ASPS comprises 94 percent of all board-certified plastic surgeons in the United States. Founded in 1931, the society represents physicians certified by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of Canada.

http://www.usnewswire.com

 
LaSandra Cooper or Brian Hugins, 
847-228-9900 or media@plasticsurgery.org

2005-12-24T05:54:00.000-05:00

By middle age, the marks of soft tissue laxity are visible on the face. The corners of the mouth are drooping, the lower eyelids have lengthened, and the malar fat pads are slipping south.

To correct these structural changes and rejuvenate the face, Paul Tessier, M.D., renowned craniofacial surgeon, first described the "midface lift."

However, putting the tissue back where it belonged and holding it there was not an easy matter. Surgeons encountered three problems: difficulty of dissection, difficulty of fixation and unpredictability of results.

Attempts to "improve" on Dr. Tessier's procedure led to a profusion of individualized techniques but only modest gains in ease or predictability. Today, the midface continues to be the most complicated and frustrating operation that many surgeons perform.

Altering midface dynamic

In October 2003, the U.S. Food and Drug Administration (FDA) cleared the Endotine Midface developed by Coapt Systems for subperiosteal midface suspension.

Packaged with disposable insertion tools, the implant is a small, five-tined platform attached to an ultra-thin leash. The tines grip subdermal cheek tissue, spreading tension over a broad area. Once implanted, the L-lactide/glycolide device begins to dissolve as tissues reaffix to the zygoma and maxilla. At five months, only 40 percent of the initial mass remains. At 12 months, the device is completely reabsorbed.

After using the implant in more than 75 patients (about half of them enrolled in clinical trials), we conclude that the Endotine makes fixation easy, fast and adjustable--without the awkward, unpredictable and hazardous placement of sutures. Operating time is markedly reduced by as much as an hour overall. Most importantly, results are predictable and often dramatic, leading to uniformly satisfied patients.

Patient selection

Patient selection is a key factor in good outcomes. The target population is 40- to 60-year-old women and men who have minimal to moderate laxity and good elasticity.

Younger patients get more dramatic results with improvements extending from the eyes to the lower midface and jowl. Benefits to older patients are concentrated in the upper midface. We do not recommend the procedure for patients over the age of 60 because attachment between periosteum and soft tissue is too lax.

Unfamiliarity

Very few patients are familiar with the midface lift.

Some arrive for consultation with a browlift in mind but later opt for a combination of browlift and midface lift. This produces synergistic results that are more dramatic than the midface alone. Other patients seek a "natural" slightly younger look with minimal discomfort and downtime. A third group--generally in their 50s--has already had surgical intervention to the lower face and neck but complains that this did not produce a healthy, rejuvenated appearance.

Overall, the midface is ideal for patients who have been receiving botulinum and dermal filler treatments and are now willing to move on to a procedure that has fewer stigmata and less scarring and potential hairline alterations than a full facelift. We look at the midface as a "transitional" procedure, not as a replacement for the facelift.

Implanting the device

The Endotine maybe inserted through incisions in either the temporal or buccal sulcus areas. The dissection phase of the operation remains largely unchanged, whether using an open or endoscopic approach.

If the Endotine is implanted through the temporal incision, the device is introduced using the insertion tool. If the Endotine is implanted through an oral incision in a retrograde fashion, it helps to first trim the edges of the leash so passage is smoother. The device is then introduced through the mouth, grasped (via temporal incisions) with forceps, and pulled through.

Regardless of point of entry, the device sits over the maxillary antrum, not the zygoma. After the insertion tool is retracted, digital pressure to the exterior of the cheek forces the tines into the periosteum. Tension on the leash completes the engagement process and lifts the periosteum along with attached skin and soft tissue. Surgeons can quickly experiment with vectors and degrees of tautness until the desired aesthetic is achieved. Finally, the leash is sutured to deep temporal fascia, and all incisions are closed.

More dramatic results

Combining the midface with a browlift will produce more elevation and, therefore, more dramatic results. (In fact, overcorrection is now a possibility.) The operation takes about 50 percent longer than a browlift alone.

In the postoperative phase, patients need to be on a soft food diet and warned against heavy lifting or straining. Bruising and edema should resolve within seven to 14 days. The recovery period can be reduced by diligent use of ice compresses for the first 48 hours. Some patients, especially thinner ones, may complain of discomfort upon palpation. However, this has not been a significant issue. Placement of the device is sufficiently distant from the facial nerve branches (frontal, orbital and zygomatic) that nerve damage is unlikely. Depending on the extent of dissection, a rare patient may experience nerve weakness during brow elevation, closure of eyes, or elevation of the corner of the mouth. This is a temporary issue, unrelated to fixation; it should resolve within six weeks.

In the first 75-plus consecutive patients, there have been no complications, no extrusions, no instances when the lift slipped, and no requests for removal of the device.

Benefits of sutureless fixation

The problems with sutures are numerous. It takes time to prepare and place the sutures. They have to be threaded up to the brow like puppet strings. Adjustments to tension or vector are difficult to achieve and time-consuming.

If placed in the wrong position, sutures must be removed and redone. This leads to multiple puncture points, which are vulnerable to infection. Sutures that remain in place may break, entrap nerves, tear through tissue or cause dimpling.

Use of the Endotine Midface eliminates all of these problems. (It is especially helpful in patients who have more tissue mass, such as men.) Achieving symmetry is easy and fast. If necessary, surgeons can go back in and reposition the device or tighten the lift for a period of several weeks after surgery.

In the past, we've experienced redo rates of around 10 percent. The Endotine also eliminates that. There is only one trip to the operating room. Any needed adjustments can be quickly made in the office under a local anesthetic. Finally, because the device is bioabsorbable, there is no need to remove sutures.

The Endotine is the first device specifically designed for subperiosteal midface tissue fixation. It shaves 30 to 60 minutes and a lot of frustration from a standard operation.

Conclusion

The midface lift, when approached through intraoral or temporal incisions and matched to the Endotine, effectively addresses the concerns of middle-aged women and men who want to look rejuvenated in a subtle, natural way with less bruising, swelling and downtime.

Patients who have had a forehead lift in conjunction with the midface suspension appear to be the happiest. Many report favorable comments from friends and family, leading to a high level of satisfaction.

Dr. Berkowitz is a plastic surgeon based in the San Francisco Bay Area. Dr. Beeson has a private practice in Carmel, Ind., where he performs otolaryngology/head, neck and facial plastic surgery. Dr. Moscoe is a plastic surgeon in Austin, Texas.

Disclosure: Drs. Berkowitz, Beeson and Moscoe have served as clinical investigators for Coapt Systems. Dr. Moscoe has no financial interest in the company. As members of the Coapt medical advisory board, Drs. Beeson and Berkowitz have stock option grants.

2005-12-20T03:37:00.000-05:00

National Report--As the cosmetic revolution continues to sweep across the country, health plans are beginning to acknowledge that millions of Americans--many of whom are managed care patients--want smoother skin and sculpted waistlines. With 8.3 million women and men undergoing some form of cosmetic surgery in 2003, health plans are taking a closer look at this growing trend to better serve their members.

A small handful of health plans have ventured into this uncharted territory and are offering their members new cosmetic services that would have been unheard of five years ago. Two Blue Cross and Blue Shield plans are providing customers with discounted cosmetic services to a network of physicians, and Kaiser Permanente, making the boldest move in the industry, has opened new cosmetic centers throughout northern California that offer everything from chemical peels to facelifts for members--and non-members.

Cosmetic procedures are not the only non-traditional benefits being offered by health plans. Many insurers now routinely cover chiropractic care, and alternative medicine is quickly becoming a covered benefit. Other health plans are starting to offer discounts on LASIK surgery, gym memberships and subscriptions to health magazines.

Consultant Patricia Burgess says that offering these "value-added services" marks the dawn of a new era in managed care. "Many health plans are running out of ways to compete, and lifestyle benefits are one of the few areas still remaining that can differentiate a managed care organization from its competitor down the street," explains Ms. Burgess, of Atlanta-based Cosmetic Surgery Consultants and author of the book "Cosmetic Surgery Without Fear."

For now, health plans are cautiously entering the prosperous field of cosmetic services--an area of medicine that has been shunned by insurers for decades. But with demand for cosmetic procedures skyrocketing, health plans are taking another look at this growing market.

"Managed care organizations are doing this to be more member friendly," comments Ms. Burgess, formerly with U.S. Healthcare. "Health plans have a vested interest in doing this because they want to direct members to qualified doctors to prevent unsatisfactory procedures."

Ms. Burgess adds that many health plans are unknowingly paying for complications resulting from cosmetic surgery. As an example, she explains what happens when a rhinoplasty is unsuccessful. "If a CPT code comes through as a nasal valve collapse, the doctor or patient will probably not say it was the result of poor cosmetic surgery. It's just going to come through as a reconstructive cost to the company. If health plans can direct people to good-quality doctors to begin with, they will minimize the cost of corrective surgeries."

Cosmetic ventures

One of the earliest experiments to offer discounts on cosmetic services failed, however. UnitedHealthcare of Georgia offered discounts to members under a pilot project started in 1999. Plan administrators decided to reduce complications by developing a network of nearly 20 cosmetic surgeons who met certain quality standards. Under the program, United's members received discounted consultation visits to Burgess' company, which provides advice and guides people to a network of cosmetic surgeons and dermatologists who meet national quality standards.

While United never supported the program with an extensive marketing campaign, word still spread quickly to members. But after a few months, the program lost support when executive leadership changed hands at the company.

Undeterred by UnitedHealthcare's failed attempt, BlueCross and BlueShield of North Carolina kicked off a program in October 2001 to provide discounted cosmetic services. Eight cosmetic surgery practices participate in the network, and more than 2,200 members have called a toll-free referral line since the program's inception. The practices offer a flat 15 percent discount on surgery costs; anesthesia and facility expenses are billed at the full amount.

Another experiment with discounted cosmetic services provided by BlueCross and BlueShield of South Carolina enlists two established cosmetic surgery practices to provide discounted cosmetic procedures to its 1.4 million members. The discounts will average about 20 percent for eight common procedures.

BlueCross BlueShield of South Carolina also signed up Charleston Plastic Surgery, headed by Tracy Harvey, M.D., and Richard Hagerty, M.D. The health plan has not determined how many other practices it might add, comments Rick Gallion, director of complementary health care.

The program, which took effect in September 2002, offers discounted rates for eight procedures: facelifts, nose reshaping, eyelid surgery, breast reduction, breast lifts, tummy tucks, liposuction and Botox treatments. After the discount, an upper and lower eyelid surgery will cost members $2,915, and a rhinoplasty will be $3,575. It normally costs patients about $4,400.

"Cosmetic surgery is very popular right now, and we see this as another opportunity to add value to the insurance program that our customers already have," adds Mr. Gallion.

Kaiser's cosmetic enterprise

While the two Carolina-based Blues plans are offering discounted cosmetic services, Kaiser Permanente's doctors actually perform the services and collect the added revenue for the company.

For Kaiser Permanente, the large group-model health plan serving about 8 million members in nine states and the District of Columbia, offering cosmetic services has required its doctors and administrators to rethink how they provide care. Kaiser had never had a mechanism in place to provide fee-for-service medicine.

"As a non-profit organization, we have always been interested in quality healthcare for the patient, not in making money," says Kenneth Ellner, M.D., chief of dermatology at Atlanta-based Southeast Permanente Medical Group. "But more and more patients are asking us about procedures they read about or see on TV. They know and trust us, and prefer to have someone they know perform these procedures."

For the past eight years, Kaiser Permanente has offered some cosmetic procedures to patients at its facilities throughout the country. In Atlanta, Kaiser Permanente opened the Cosmetic Clinic last summer, offering the full gamut of cosmetic treatments.

In Los Angeles, another hotbed for cosmetic procedures, some facilities offer esthetician services such as mild chemical peels and microdermabrasion, while also selling skincare products. One clinic, run by dermatologist Myung-Moo Lee, M.D., provides laser treatment and Botox injections, sclerotherapy and laser hair removal.

But it's Kaiser Permanente's northern California region where the company has opened new clinics and added medical staff to meet the increasing demand for cosmetic services. The majority of its 22 facilities now offer cosmetic procedures, and within the next year all of them are expected to provide some level of cosmetic services, says Steve French, director of business development for the Permanente Medical Group. He estimates that as many as 20,000 cosmetic procedures have been performed in the past five years.

The clinics, called Kaiser Permanente's Centers for Cosmetic Services, offer nearly every cosmetic procedure found at a private doctor's office. Kaiser's doctors, nurses and estheticians staff the centers. Several lines of cosmetic products, which are otherwise difficult for patients to purchase, are available at the centers.

According to Michael McGuire, M.D., chair of the public education committee for the American Society for Aesthetic Plastic Surgery, Kaiser Permanente's cosmetic program has had virtually no impact on the market. He explains: "Because Kaiser's doctors are paid on a salary basis, there's not much incentive for them to perform a lot of cosmetic procedures, and its patient population tends not to be an affluent group who can afford cosmetic surgery from Kaiser or elsewhere."

Dr. McGuire adds: "Doctors who are not real plastic surgeons attempting to do cosmetic surgery have a much bigger economic effect on the market than Kaiser's program."

Whether Kaiser will become a major player in the cosmetic marketplace remains to be seen. The medical group still has big dreams for its cosmetic program. Since 2000, the company has opened four stand-alone cosmetic centers. Already, all four centers are profitable with annual revenue growth of 15 to 20 percent, says Mr. French. "It's possible in the next couple of years, we could see a few more centers open up in Northern California if there is demand for them."

2005-12-13T11:06:00.000-05:00

Byline: LINA DAS

Braving bad weather and bad-tempered cows, ten spoilt youngsters, from some of the richest and most famous families, herd 200 cattle over 100 miles of mountainous terrain in the U.S.

state of Colorado for a new TV show. They are roughing it in campsites for a month, all in aid of raising money for mentally and physically disabled children. But, far from being judged on their herding performance, it was team work and attitude that counted.

And you can't buy that anywhere.

The Hon ALEXANDER CLIFFORD, 19, son of the 14th Baron Chudleigh, is set to inherit Ugbrooke, the historic family home in Devon and its 3,800-acre estate. He says:

When I first met the others, travelling on the private jet to Colorado, the talk was all of Gucci and Prada. The conversations were littered with phrases such as, 'I think Gucci even has their own cowboy range now.' I've been taught not to judge people, but I didn't need to because the stereotypes were there.

With the odd exception, like Alex [son of the actor Anthony Quinn], I felt they were all superficial and materialistic. I was astounded at how much pocket money they got. One girl was getting more than [pounds sterling]4,000 a month for expenses. She was great fun, but she was a spoilt brat - pretty much all of them were. I was the odd one out, really.

I went to Millfield public school and have been around people with money all my life, but I think it's important to be able to handle it. It does help if you can do that with class.

They just don't have that - they are nouveau riche. They asked me about my allowance - I have one, but not on their scale - and I said that we just don't talk about money in Britain.

It was so ludicrious to hear that Fabian's [a Manhattan It boy] monthly phone bill alone is [pounds sterling]1,600 that you had to laugh. Fabian is the king of complainers. He doesn't accept 'no' for an answer and his rules are never to get hurt, never get dirty and never put himself out.

He flashes around his black American Express card, which is only issued to the super wealthy and which his Daddy obviously pays for - he's money, money, money. He even couriered out tequila, two digital cameras, and one of each of Pizza Hut's pizzas - all on separate deliveries - to the cattle drive, which was in the middle of nowhere. When he couldn't be bothered to wash his dirty underwear, he couriered out 30 pairs of designer boxer shorts and matching T-shirts.

My father brought me up to treat money with respect. We are not ridiculously rich - it's all tied up in land - so I've never had cash flashed in my face like they have. I went shopping with the girls after the show and they spent [pounds sterling]2,000 in one spree. It was crazy. I could never fall for one of those girls - no, no, no. I'd be broke. If I brought someone like them home I'd lose my inheritence.

I was amazed to see one girl bring an entire set of Louis Vuitton luggage with her. I had a wheelie suitcase, which became the laughing stock of the group and was nicknamed 'the Tupperware box'. I didn't mind because I teased the Americans, saying that I have chairs in my house that are older than their country.

I have grown up in a beautiful home designed by Robert Adam with gardens designed by Capability Brown. The dining room table can sit 25. The house is open to the public for a limited season. It is a home, albeit grand. I'm inviting the Cattle Drive group over for a dinner party and they will be able to see another side of the concept of wealth.

A lot of the behaviour was cringeworthy and I felt some of the others looked down on the cattle drive cowboys, who showed us what to do, whereas I got on well with them. Most of us, however, came back humbler - with the exception of Fabian, who became more obnoxious and said that he appreciated room service even more.

COURTENAY SEMEL, 23, is the daughter of Terry Semel, CEO of Yahoo! and the former boss of Warner Bros. She is single and lives in West Hollywood. She says:

When I was nine, I had a role in the movie Hudson Hawk as a bratty kid and, when it came to Cattle Drive, I gave the show a brat times ten. I could have been on my family's yacht, but I did this instead. I honestly thought we were going to have a trailer with a hair stylist and a makeup artist. Showering was a nightmare. We had to pour buckets of water over our heads. I could barely lift mine and there was always a brown film at the bottom of the bucket. In the end I gave up on showering, even though I felt disgusting.

I thought that Joshua, the cattle drive boss, was picking on me. I couldn't get on my horse because my jeans were a bit tight and Joshua said that that should teach me not to wear Gucci jeans. But he got it so wrong. Who actually wears Gucci jeans? No one.

Alex Quinn and I hit it off but, when you're in the middle of the wilderness with cow dung on you and you can't shave your legs, then nothing romantic is going to happen.

The first night there I was very unhappy and wanted to go home. I phoned my dad to ask him to get me out, but when I got hysterical, he put the phone down. I kept calling him but he refused to help. He'd taken care of all my messups before - parking tickets, my car getting towed, me not being able to get to classes in New York because it was too cold - and wanted me to take responsibility for a change.

I was born in Beverly Hills and grew up in Bel Air. My dad was head of Warner Bros, so I grew up around film stars. Every summer, Tom Cruise and Nicole Kidman would join us on vacation. Once, when I was sick in bed, my mum asked me to come downstairs and, when I did, there were Michael Crawford and Sarah Brightman. They said, 'If you sing for us, we'll sing for you,' and they ended up singing Think Of Me from Phantom Of The Opera.

Michael Jackson came to our house, too. He said to my mum, 'Can you clean the toilet before I use it?' - although I doubt she went in there with a toilet brush. He didn't want to hang out with the adults and so he hung out with us kids in my room and we all told stories to one another.

I've known Paris Hilton ever since nursery school and, as much as people say she's dumb, she's created a formula that works for her and, businesswise, she's done really well. At school, she was wearing makeup and skirts that were too short from the age of 12.

Growing up in Hollywood makes you extra competitive. You never feel pretty or thin enough. I had eating disorders and suffered from depression. There was pressure, even when I was a teenager, to have plastic surgery.

I considered liposuction and, had I really wanted it, I'm sure my mum would have let me. At college I got into drugs and drank and went to rehab, but I'm fine now. My parents give me an allowance of [pounds sterling]4,000 a month, but I want to do something with my life, such as helping kids with drug problems and eating disorders. I hope I can be a role model.

ALEX QUINN, 28, is the son of acting legend Anthony Quinn, who died four years ago.

He is separated from his wife, and lives and works in Los Angeles as an actor. He says: When I was deciding whether to do the show or not, I considered what my father would have thought and was mindful of his legacy.

He was a very outdoorsy, rugged man, and I think he would have encouraged me to do it. He would have loved to have done a cattle drive, but he would never have done a reality television show.

I enjoyed being on the cattle drive. The physical aspect was challenging but not difficult. The hardest part was being around some of the complaining and the negativity of the others. Some of the kids had been a bit spoilt and so, when one of them complained, it tended to escalate from one person to another.

Courtenay came across as bratty, but I think she only acted like that because she knew people expected it of her. I didn't plan on having a romance while I was there, but something just happened between us. I was flattered that the women found me attractive, because, if you'd met me five years ago, you'd have seen me seven stone heavier. Getting attention from women is new to me and, although I've never felt that I had to live up to my father's reputation as a great lover of women, I've always been aware of his reputation.

My father had 13 children and I was born during a seven-year affair he had with my mother, Friedel Dunbar, while he was married to his second wife, Iolanda. My father didn't spend much time with me and my brother while we were growing up in Beverly Hills because Iolanda wouldn't let him. By the time his marriage was ending, I was 16 and we were able to have a wonderful relationship.

Life with my father was never dull. I miss the yachts in Monte Carlo, the private jets, and seeing how happy he made the people he met. But there were sad moments, too: he never came to father-son events at school. I would have to go with someone else's father.

As I got older, I fell in love with acting and he wasn't too pleased. He said, 'Fine, but don't expect me to make any phone calls for you.' At first I was hurt, but then I realised he was doing it for my own good. He wanted me to earn my own successes. He had made it from nothing and he instilled that same work ethic in me. As a result, I've always worked - he paid for my food, housing and school, but that was it.

My mum was also reluctant to give me money. I grew up with friends such as Scott Caan [son of James Caan] and Sage Stallone [son of Sylvester Stallone].

Their parents would give them [pounds sterling]50 spending money, while my mother gave me [pounds sterling]5.

It was quite embarrassing.

HAYLEY GIRALDO, 20, is the daughter of guitarist Neil Giraldo and rock singer Pat Benatar. She lives on her own in Malibu. She says:

When I agreed to do the show, I had no idea we'd be roughing it as much as we had to. We rode six hours a day and it was really hard as I had no previous ranching experience, and we ended up staying in places where there were bears and rattlesnakes. And, when it came to the actual cattle drive, I thought we'd maybe do a little and then the ranchers would do the rest, but they made us do everything they did. We even had to kill, skin and cook a rattlesnake.

Still, we all kept the skins and we're now going to make bracelets out of them.

In the beginning, we all wanted to look cute but, by the end, we gave up. We had been told not to bring really nice clothes as they'd get ruined but, of course, we all wanted to look good on TV. Someone brought five pieces of Louis Vuitton luggage with her and, in the end, all the girls just dipped into her suitcases and wore her stuff. I started out wearing these little tops, but then my straps would fall down and I'd have to keep pulling them up which would make me lose my reins and then Joshua, the cattle boss, would start shouting at me.

My parents love the show because they say I don't act like a brat. I've been touring with my mum ever since I was nine months old and I love to travel. I went to school with the children of people such as Mel Gibson, Michael Landon and Rick Springfield, but it was all very normal. No one went, 'Oh look, there's Mel Gibson.' Sometimes people would be in the house and I wouldn't have a clue who they were and it was only when I got older that I'd think: 'Oh, that was Fleetwood Mac.' And on my birthday, I'd get presents from the likes of Cyndi Lauper and Deborah Harry.

Mum never spoiled me and raised me never to take things for granted so, if I asked for a Range Rover, for example, she wouldn't just give it to me. Now I'm trying to figure out what I want to do with my life. I design jewellery and love to cook, sing, dance and act, and I've even been the warm-up on stage for my mum. I learnt a lot from the cattle drive and I think the ranchers learnt a lot from us, too. At least the cowboy, Joshua, learnt never to wear Gucci jeans.

Rich Kids: Cattle Drive is on E! Sky Channel 193 on Fridays at 10pm.

2005-12-11T14:26:00.000-05:00

Saint-Gobain Performance Plastics

5 rue du Dauphine, BP 712, Z.I. Chesnes 38297 Saint Quenten Fallavier

Cedex, France

tel. +33 474 94 82 31

e-mail an.kiebooms@saint-gobain.com

www.medical.saint-gobain.com

Vital Statistics

Number of employees: 4100

Number of facilities: 47

Who We Are

For more than four decades, Saint-Gobain Performance Plastics and its family of companies have supplied the world with innovative high-performance polymer products for the most demanding applications. This successful corporation has been built with the single purpose of serving the customer and a commitment to quality and leadership in each of the industries served. Partnering in the development of new products and advanced technologies, we serve the innovations needs of the medical device,

baby care and ergonomic health markets. Our global approach includes an unparalleled knowledge of polymers and other high-performance plastics with a particular speciality in silcone technology. We employ the polymer and application engineers to provide material and design solutions to you during the product development stage, allowing you to concentrate on the bigger picture.

Major Markets

Medical markets served: fibreoptics, haemotology, infant care, ophthalmic, othopaedic, surgery, urology, home health, anaesthesiology, cardiovascular, diagnostics, IV delivery, enternal feeding and contract manufacturing.

Services Offered

* Extrusions: Silicone, PVC, Polyurethane, Polyolefin

* Single and Multi-Lumen

* Round and Profiles

* Co-Extrusions

* Radiopaque

* Paratubing

* Custom formulations

* Moulding -- Silicone

* LIM

* Transfer

* Insert

* Automated Fabrication Cells

* Assembly of Device Components

* Printing

* Cufted Catheters/Cannulae.

2005-12-07T00:12:00.000-05:00

AP Worldstream

06-14-2005

Ld-Writethru,1141

Industry experts say Jackson could make a comeback after acquittals

Eds: LEADS with 11th grafs to UPDATE with comment from Las Vegas developer showing interest in Jackson. Picks up 11th graf pvs: `Even before ...'. Moving on general news and entertainment services.

With BC-NA-GEN--US-Michael Jackson

AP Graphic JACKSON LIFE

By NEKESA MUMBI MOODY

AP Music Writer

NEW YORK (AP) _ Michael Jackson's career has been declared dead before.

When his success as a child wunderkind fronting The Jackson Five was waning, some doubted whether he could make it as an adult star _ and were proven wrong. And when he had hits again with his brothers as part of The Jacksons, others questioned whether he could become a solo success _ and they were wrong.

After Jackson became one of the most popular entertainers in history _ and saw his image tarnished by a 1993 allegation of child molestation _ many doubted that he would have a No. 1 hit again. But he did.

Still, after being charged with molesting a young cancer patient and a seamy, graphic trial featuring an avalanche of porn and allegations of sex with young boys, can Jackson's career withstand this latest blow, even with Monday's acquittal on all counts?

According to industry analysts, the answer is of course.

"He can have success," said Antonio "L.A" Reid, chairman and CEO of Island Def Jam. "I would say that he has to just make great music and concentrate on nothing else but making great music and making great live performances."

The public hasn't concentrated on Jackson as a musical figure for a long time. His last album, a greatest hits project, was released the day of his arrest on child molestation charges in 2003. For the past year and a half, news around Jackson has centered on allegations of sex with children, giving them alcohol, and other questionable behavior at Neverland Ranch.

"People have been fascinated with Michael as a celebrity," says Jack Isquith, head of label relations at AOL Music, which premieres the latest videos, concerts and singles by the nation's top pop acts.

"He has declined in terms of his record sales and his musical standing ... there's no question that Michael has been perceived on the wane," Isquith said. "(But) if Michael Jackson were to play the Apollo and it was monumentally brilliant ... I think that would really register a lot of focus on Michael as a musical (figure)."

Las Vegas might be a possibility for him to make that great live performance. On Tuesday, Jack Wishna, who has a minority interest in Trump's New Frontier Hotel and Casino, said he had been in talks with Jackson before the trial to perform on the Strip, and hopes to continue those negotiations.

"I am still interested in bringing his talents to Las Vegas," he said in a statement.

Even before the trial, Jackson's musical career had taken a backseat to his increasingly bizarre behavior _ from extensive plastic surgery to holding his infant son over a balcony. And his career was seriously damaged by the 1993 child molestation accusation.

That case went away when Jackson paid a multimillion-dollar settlement while maintaining his innocence, and no criminal charges were filed. Since then, Jackson has released just two albums that have sold about 2 million copies each _ great numbers for most artists, but considered a flop given Jackson's previous stellar sales.

Still, he had retained his star power _ a 2001 concert paying tribute to his 30 years in music featured a who's who of celebrities and legends, including Destiny's Child, Marlon Brando, Liza Minnelli, Whitney Houston, 'N Sync, Britney Spears and Elizabeth Taylor.

"To sell two million records says a lot," Reid noted. "By the way, I'm not sure how many records Madonna sold, but I don't think it's very much more than that, probably about that."

Actually, it was less _ her 2003 album "American Life" struggled to reach 1 million in sales.

Yet, there is a considerable "ick" factor when it comes to Michael Jackson. Though acquitted of child molestation, most people have been repulsed by his admission to sleeping in the same bed with children, even if it was non-sexual. He also carries plenty of baggage given his eccentric behavior over the years and plastic surgery that has reduced him to a disturbing visual image.

But negative publicity _ no matter how unseemly _ doesn't necessarily mean the end of a career anymore.

Take R. Kelly. In 2002, videotapes circulated showing a man bearing a striking resemblance to Kelly having sex with what appeared to be an underage girl _ and then urinating on her. Later that year, he was charged with child pornography, and pundits declared his career over.

A year later, he released the critically acclaimed "Chocolate Factory" _ which debuted at the top of the charts. Since then, he has released two other platinum projects, and worked with several top acts, including Britney Spears and Jay-Z.

DJ Paul Cubby Bryant, of New York City pop radio station Z100, said that if Jackson put out new music, he would let the audience decide its fate. "I think we would test the waters, and play it and see what the reaction was," Bryant said.

Of course, Jackson faces plenty of challenges in making a comeback. First, he doesn't have a label home _ his commitment to Sony Music is just about over, and given the acrimony that relationship devolved into in recent years, he won't likely be recording a new album for them.

But Reid has said he would sign him, and Jackson already has at least one top producer willing to work with him.

"I would do records on Michael Jackson," said multiplatinum artist Missy Elliott in an interview with The Associated Press recently. "Michael Jackson, he went through his thing where I think he was the biggest I think he could ever be. Of course, I don't think it would come back to that, but you've got a lot of people out there who respect and love Michael, like loyal fans."

One pundit said his criminal case has been a career boost, and predicted a public rehabilitation of his reputation, a la Martha Stewart.

"I think that his acquittal will be enormously helpful to his career. Now he has the David and Goliath (parallel) on his side," said Paul Levinson, Chairman of Media and Communications at Fordham University. "He stood up to the government... He proved almost all the pundits wrong."

As far as refurbishing his tarnished image? Reid said that should be the last of Jackson's worries. "That's how he got in trouble, by changing his image... Let the music do the talking, leave the rest of it alone."

Copyright 2005, AP News All Rights Reserved

2005-12-02T01:53:00.000-05:00

KRT Photos

03-17-2005

US NEWS MED-NEWEARS 3 SL

KRT US NEWS STORY SLUGGED: MED-NEWEARS KRT PHOTO VIA ST. LOUIS

POST-DISPATCH (March 22) Nicholas Kossman, shown in this family

photo when he was 2 years old, was born without normal ears so

a plastic surgeon crafted new ones for him. (gsb) 2005 (Diversity)

Document Name|US NEWS MED-NEWEARS 3 SL

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Document Date|Mar/17/2005

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Photographer |HANDOUT

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Format |2200 x 1486 Color JPEG

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Category |A DIV

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Keywords |krthealthmed, krtnational national, krthealth

|health, krtkidhealth kid, krtedonly, krtdiversity

|diversity, woman women, youth, 2005, krt2005,

|plastic surgery, ear, youth, child, deformity,

|corrective surgery

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© 2005 Knight-Ridder/Tribune News Service

2005-11-30T02:12:00.000-05:00

The Record (Bergen County, NJ)

08-01-2004

Separation near for twins -- Joined at head, surgery is set for Wednesday

By JIM FITZGERALD, THE ASSOCIATED PRESS

Date: 08-01-2004, Sunday

Section: LOCAL

Edtion: All Editions.=.Sunday

NEW YORK - If all goes well during a daylong operation Wednesday, Carl and Clarence Aguirre, 2-year-old twins from the Philippines joined at the top of their heads, will wake up in separate beds.

For the first time, they'll be able to look into each other's faces. And they should soon be able to sit up, stand straight, and walk for the first time - no longer the toddlers who couldn't toddle.

"I can't wait to see how they react," said Dr. David Staffenberg, the plastic surgeon on the team that plans to separate the boys at Montefiore Medical Center in the Bronx. "I can imagine them looking at each other and thinking, 'I know that guy, but how come he's over there?'-"

Since last year, Carl and Clarence have been the focus of a determined effort by their mother, Arlene Aguirre, as well as two hospitals and a medical team donating their services. The doctors have taken a surgical approach employed only a few times before on conjoined twins, replacing the typical marathon two-day operation with four shorter procedures over 10 months.

The aim is not only the survival of both boys - often one twin dies, even if one makes it through such surgery - but to increase their long-term chances without major complications.

Still, Staffenberg said, success is "very far from a done deal. There's lots that could go wrong."

In previous operations, the boys' skull was opened, their separate-but-touching brains carefully pushed apart, and most of their shared blood vessels cut and divided.

Magnetic resonance images show that the boys now have nearly equal, thriving circulation systems, said Dr. James Goodrich, the lead surgeon. What had been dormant veins on Carl's side have plumped up and assumed the duties of veins on Clarence's side that had been doing the circulation work for both boys.

Like those operations, Wednesday's surgery will be alarmingly delicate.

Goodrich and Staffenberg will cut through skin and bone to open a window on the brains and the surrounding blood vessels. The major vein the boys still share will be cut and divided.

The last area where the brains are touching - about an inch and a half across, Staffenberg said - will be teased apart while doctors keep a sharp eye out for any connecting veins.

"If you just say, 'We're done,' and yank them apart, you wind up with a lot of bleeding and all these strokes, which is an issue we've been trying so hard to avoid," Staffenberg said.

It's difficult work, even with the help of magnifiers. The surgeons have described the tiny veins as having "the consistency of wet toilet paper."

The team will check for excessive bleeding or swelling before deciding whether to continue with the separation. "There's always another day," Goodrich said.

Once the decision is made to go ahead, the last of the connecting skull bone, including a large portion that "flares out in the wrong direction," will be removed, Staffenberg said. The boys' head-to-head tables can then be moved apart to give the doctors more room.

Staffenberg will then have to reconstruct the dura mater, a membrane that covers the brain. Though the boys have separate brains they shared the membrane, and extra material will be needed to cover both brains. It could come from the boy's midsection or a commercially available substitute, he said.

"The dura is the layer that keeps the cerebral spinal fluid in around the brain," he said. "You don't want that leaking."

The next step is to "wash everything out and then start closing the skin," Staffenberg said. He will leave the reconstruction of the skulls - a major project - for later.

"I had to be sure in designing [the procedure] that their hair was going to be growing in the right direction," Staffenberg said. "I didn't want them to have these big cowlicks."

For a finishing touch, Staffenberg said, "I made the suggestion that we put them both into Yankees caps. This is the Bronx."

Aguirre, the boys' mother, brought them to New York from the Philippines in September and lives with them at Blythedale Children's Hospital in Valhalla, N.Y., between surgeries at the Children's Hospital at Montefiore. She has chosen not to be in the operating room, Staffenberg said, but will get regular updates during the surgery.

Illustrations/Photos: PHOTO - ASSOCIATED PRESS - Arlene Aguirre watching her conjoined twins, Carl, right, and Clarence, at The Children's Hospital at Montefiore in the Bronx. The twins are to be separated in a daylong operation.

Keywords: YOUTH, SURGERY

Copyright © 2004 Bergen Record Corp. All rights reserved.

2005-11-19T21:05:00.000-05:00