Beautify Me !

The Stress of Cancer: Seeking Support


Learning that you have a diagnosis of cancer is usually a traumatic experience. And following the shock of diagnosis, people have to face treatment decisions and side effects, changing personal relationships and uncertainty about their future.

"Stress can appear at every stage of the disease, at diagnosis, during treatment and after treatment," says Josée Savard, PhD, a professor of psychiatry at Université Laval in Quebec, Canada. While some stress is expected to accompany a diagnosis of cancer, Dr. Savard and other experts say that people with cancer should monitor their stress levels to make sure they are not crossing the line into depression and anxiety, which are conditions that can interfere with someone's quality of life and even their health status.



Stress vs. Anxiety and Depression
Most of the research on the psychological impact of cancer has been conducted in women with breast cancer. It's estimated that between 22 and 50 percent of women with breast cancer are depressed, while 33 percent have acute stress disorder and 3 to 19 percent have post-traumatic stress disorder (PTSD), a condition seen in people who have experienced traumatic events such as natural disasters or military combat.

A Canadian study published June 14th in the British Journal of Cancer found that almost 38 percent of its 3,095 participants—who included people with breast, prostate, colorectal and lung cancer—met the criteria for distress levels that should be treated. But almost half of these patients had not sought psychosocial support, primarily because they weren't aware of support services or because they didn't think they needed them.

According to study author Linda Carlson, PhD, a clinical psychiatrist with the University of Calgary/Tom Baker Cancer Centre in Alberta, Canada, not getting help can have major repercussions. "If people don't feel like they can talk to anyone, their distress just snowballs over time," she says, adding that people with untreated depression and anxiety often end up visiting doctors more often.

That snowball effect may be one of several reasons patients find the post-treatment period stressful. "Some patients find it most difficult when treatments end because they feel they're not fighting anymore and they don't have the support of their medical team," Dr. Savard says.






Getting Support
Sometimes people with cancer find that the friends and family they thought they could rely on aren't offering them the support they need. In fact, cancer can sometimes expose existing cracks in relationships, particularly in couples. "For couples who were functioning well before cancer, the cancer will usually have a minimal impact on their relationship, or even improve it. In couples who had difficulties before cancer, it will generally create more problems," Dr. Savard explains.

Other times, Dr. Carlson says, people don't want to overburden their friends and family with their worries and may feel pressure to stay upbeat. And those friends and family members don't always know what to say or how to be helpful, especially if they haven't faced a life-threatening illness themselves.

Many people with cancer find the support they need in psychotherapy. Depending upon someone's personality and preferences, they may choose one-on-one psychotherapy or a support group of their peers that is led by a mental health professional, such as an oncology social worker. A study published in May 2001 in The Archives of General Psychiatry found that support groups helped reduce distress in people with metastatic cancer, primarily by helping them face their advanced disease on an emotional level. (Because the concerns of people with early stage and advanced cancer are so different, separate support groups are often found to be helpful for participants.)

"Supportive treatment, whether it's individual or group therapy, allows people to express their concerns and fears," Dr. Carlson says. "There's this myth that you have to be positive all the time when what's really important is that people are able to express their feelings, whatever they are."

Support groups and psychotherapy are also available to the family and friends of people with cancer. People with cancer and their families can find psychosocial support though their hospital or cancer center, or though support and advocacy organizations such as the American Cancer Society and The Wellness Community and CancerCare, which offer online support groups led by health professionals.

Other options available to people with cancer include hypnosis and guided imagery, where you relax by focusing on a positive mental image. Biofeedback, a technique that helps people learn how to relax, works with bodily functions such as breathing and muscle tension. If it's feasible, mild aerobic exercise can also provide energy and a mood lift. Some people, especially those who have had anxiety disorder or depression in the past, may need antidepressants or anti-anxiety medications to help them cope.

Cancer is an isolating experience, Dr. Carlson says, but reaching out for support can help people living with the discomfort and uncertainties of cancer gain reassurance and a better quality of life.

National Cancer Institute's Symptoms of Depression Having a depressed mood for most of the day and on most days:

Loss of pleasure and interest in most activities
Changes in eating and sleeping habits
Nervousness or sluggishness
Tiredness
Feeling of worthlessness or inappropriate guilt
Poor concentration
Thoughts of death or suicide

More Than Mood Swings: Bipolar Disorder in Teens


Parents are often exasperated by their moody teenage children. After all, teenagers are known to be irritable, to sleep a lot and to resist authority figures. So how can a concerned parent determine when a teenager is just being a typical teenager and when their child has a mental illness such as bipolar disorder?

In teenagers, symptoms of bipolar disorder can include dramatic mood changes within a single day and may have different symptoms than adults. Below, Barbara Geller, MD, a professor of psychiatry at Washington University in St. Louis, discusses how to recognize and treat bipolar disorder in adolescents.



What is bipolar disorder?
It's defined like other psychiatric disorders across the age span in a manual called the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The specific definition for what we now call bipolar disorder, but used to be called "manic-depressive" illness includes certain symptoms that patients must have to make a diagnosis.

People have to experience both depressed and manic episodes. For example, to fit the depressed part, they would need to be sad, to lose enjoyment in usual activities, to have trouble sleeping and eating, to be guilt-ridden, suicidal. To fit the manic part, they'd have to have elation: a mood of being happy as if the most wonderful thing in your life is happening except it's on a day that's like any other day. Families often describe it as Jim Carrey—like behaviors: silly, giddy, joking without an apparent reason.

People with bipolar disorder also get very grandiose. In adults, it may be developing business schemes that are unlikely to work so they wind up maxing-out credit cards. They have very active personal lives and may have multiple marriages. They seem to be able to go without sleep and are very social.



When does bipolar disorder usually first appear?
It's really only been in the last decade that people have started to pay attention to diagnosing bipolar disorder in young children and early adolescents. So many adults looking back can describe that they had the illness, but it may not have been recognized at that time. It's estimated from current studies that maybe as many as half of adults who have bipolar disorder had their onset before age 17.



How is the bipolar disorder different in younger children?
In adults, what people are used to thinking is that there will be a discrete episode with a clear onset and a clear offset. You generally have mostly a high or a low, and people function somewhat better between episodes.

What we see in the younger population is they have continuous illness for years, but on a daily basis, they can be both high and low. So they may spend four hours of the day high and giddy and silly, and it's very infectious and amusing, and maybe another four hours of the day morose, gloomy, not wanting to be with friends and thinking of hurting themselves. You see these very rapid cycles shifting from extreme high to extreme low on a daily basis, day in and day out, year after year.

And in children, the high manifests a little differently because children are not likely to max-out credit cards or have had four marriages by the time they're seven or eight. So what we look for in children is being super happy, as if it were Christmas morning or the day you're going to Disneyland, except it's the average day in school.



What are some of the risk factors for bipolar disorder?
The biggest factor is that it seems to run in some families. Bipolar symptoms also can occur with use of certain prescription medications such as steroids, with some illicit drugs such as cocaine and with various brain diseases such as stroke, tumors and trauma.



What are some of the warning signs in teenagers?
What families may notice is an exaggeration of all the stereotypes of what we say teenagers do. So we think of teenagers as being irresponsible and being irritable, but the child with bipolar disorder may suddenly decide, "I'm not going to school. They're not teaching me anything. I'm going to be President of the United States anyway, why do I have to go to school?" They have very grandiose behaviors that are out of keeping with reality.

They can also get very hypersexual. We think of adolescents getting very interested in the opposite sex, but bipolar adolescents will feel an urgent need to have multiple partners. They'll begin using very sexy language in inappropriate places. At school, they may write it on the blackboard.

How can parents distinguish between a moody teenager and someone who might have a mood disorder?

It's extremely important for parents to get a professional evaluation if they have any suspicion. The worst that will happen, if it's unfounded, is they will have spent a little time and money. But if it is not evaluated, and you let it go on, it can devastate a child's life. There will be multiple suspensions from school. They can get sexually transmitted diseases because they have unsafe sex. They can very rapidly go into a depression and get very suicidal and act on it. So it's very important, especially in families where a family member has bipolar disorder or has depression, for parents to get consultations at the first sign of any suspicion.



Are teenagers with bipolar disorder more likely to have drug and alcohol problems?
There is a very high rate among people with bipolar disorder of using alcohol and drugs across the age span. Parents have to be very suspicious because a child who's using drugs may seem like they're just having "the normal moodiness of adolescence."

There are some common things to look for. For example, drugs cost money and the family may find that items are disappearing from the house. A child may ask to borrow Mom's jewelry, and it somehow gets lost. Or they borrow electronic equipment, and what they're doing is selling it so they can afford their drugs.



What treatment is recommended to teenagers with bipolar disorder?
There are three classes of medication that are used for bipolar illness across the age span. The antimania drug lithium is the mainstay, and lithium is especially good if somebody else in the family with bipolar disorder has responded to it. The second class of drugs is called anticonvulsants because they were originally developed to treat epilepsy. And the third class of drugs is called neuroleptics.

It's very important to educate the family about the illness and to let them grieve. The last thing they want is for one of their children to have the illness. Then you can help them adapt and take part in the child's treatment. You also have to educate personnel at the school so that the expectation about the amount of work that the child can do is geared toward what the child can manage.



How well does medication control the disease?
Some kids do very well and become indistinguishable from other children as long as they take their medication regularly. The medication essentially has to be taken indefinitely, as it is in adults. Most who take it regularly will have fewer hospitalizations and suicide attempts, and they will be able to hold jobs better and have more stable personal relationships. For others, bipolar disorder is very difficult to treat, and it can be months of trying to find the right combination of treatments.



Are there strategies for helping teenagers stay on their medication?
Strategies have really not been formally researched and developed. This is a very important area for future research. For example, will there be Web-based programs the patients can go to? One thing that we find very helpful to do with adolescents is to grieve with them. The way parents have to mourn the loss of a child who's well, the children themselves have to mourn the loss of their former well self.

But grief hurts a millimeter less every day, so we usually can tell them that six months from now, it'll be more automatic just to take the medication and go about your other business.

More Than Mood Swings: Bipolar Disorder in Teens


Parents are often exasperated by their moody teenage children. After all, teenagers are known to be irritable, to sleep a lot and to resist authority figures. So how can a concerned parent determine when a teenager is just being a typical teenager and when their child has a mental illness such as bipolar disorder?

In teenagers, symptoms of bipolar disorder can include dramatic mood changes within a single day and may have different symptoms than adults. Below, Barbara Geller, MD, a professor of psychiatry at Washington University in St. Louis, discusses how to recognize and treat bipolar disorder in adolescents.



What is bipolar disorder?
It's defined like other psychiatric disorders across the age span in a manual called the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The specific definition for what we now call bipolar disorder, but used to be called "manic-depressive" illness includes certain symptoms that patients must have to make a diagnosis.

People have to experience both depressed and manic episodes. For example, to fit the depressed part, they would need to be sad, to lose enjoyment in usual activities, to have trouble sleeping and eating, to be guilt-ridden, suicidal. To fit the manic part, they'd have to have elation: a mood of being happy as if the most wonderful thing in your life is happening except it's on a day that's like any other day. Families often describe it as Jim Carrey—like behaviors: silly, giddy, joking without an apparent reason.

People with bipolar disorder also get very grandiose. In adults, it may be developing business schemes that are unlikely to work so they wind up maxing-out credit cards. They have very active personal lives and may have multiple marriages. They seem to be able to go without sleep and are very social.



When does bipolar disorder usually first appear?
It's really only been in the last decade that people have started to pay attention to diagnosing bipolar disorder in young children and early adolescents. So many adults looking back can describe that they had the illness, but it may not have been recognized at that time. It's estimated from current studies that maybe as many as half of adults who have bipolar disorder had their onset before age 17.



How is the bipolar disorder different in younger children?
In adults, what people are used to thinking is that there will be a discrete episode with a clear onset and a clear offset. You generally have mostly a high or a low, and people function somewhat better between episodes.

What we see in the younger population is they have continuous illness for years, but on a daily basis, they can be both high and low. So they may spend four hours of the day high and giddy and silly, and it's very infectious and amusing, and maybe another four hours of the day morose, gloomy, not wanting to be with friends and thinking of hurting themselves. You see these very rapid cycles shifting from extreme high to extreme low on a daily basis, day in and day out, year after year.

And in children, the high manifests a little differently because children are not likely to max-out credit cards or have had four marriages by the time they're seven or eight. So what we look for in children is being super happy, as if it were Christmas morning or the day you're going to Disneyland, except it's the average day in school.





What are some of the risk factors for bipolar disorder?
The biggest factor is that it seems to run in some families. Bipolar symptoms also can occur with use of certain prescription medications such as steroids, with some illicit drugs such as cocaine and with various brain diseases such as stroke, tumors and trauma.



What are some of the warning signs in teenagers?
What families may notice is an exaggeration of all the stereotypes of what we say teenagers do. So we think of teenagers as being irresponsible and being irritable, but the child with bipolar disorder may suddenly decide, "I'm not going to school. They're not teaching me anything. I'm going to be President of the United States anyway, why do I have to go to school?" They have very grandiose behaviors that are out of keeping with reality.

They can also get very hypersexual. We think of adolescents getting very interested in the opposite sex, but bipolar adolescents will feel an urgent need to have multiple partners. They'll begin using very sexy language in inappropriate places. At school, they may write it on the blackboard.

How can parents distinguish between a moody teenager and someone who might have a mood disorder?

It's extremely important for parents to get a professional evaluation if they have any suspicion. The worst that will happen, if it's unfounded, is they will have spent a little time and money. But if it is not evaluated, and you let it go on, it can devastate a child's life. There will be multiple suspensions from school. They can get sexually transmitted diseases because they have unsafe sex. They can very rapidly go into a depression and get very suicidal and act on it. So it's very important, especially in families where a family member has bipolar disorder or has depression, for parents to get consultations at the first sign of any suspicion.



Are teenagers with bipolar disorder more likely to have drug and alcohol problems?
There is a very high rate among people with bipolar disorder of using alcohol and drugs across the age span. Parents have to be very suspicious because a child who's using drugs may seem like they're just having "the normal moodiness of adolescence."

There are some common things to look for. For example, drugs cost money and the family may find that items are disappearing from the house. A child may ask to borrow Mom's jewelry, and it somehow gets lost. Or they borrow electronic equipment, and what they're doing is selling it so they can afford their drugs.



What treatment is recommended to teenagers with bipolar disorder?
There are three classes of medication that are used for bipolar illness across the age span. The antimania drug lithium is the mainstay, and lithium is especially good if somebody else in the family with bipolar disorder has responded to it. The second class of drugs is called anticonvulsants because they were originally developed to treat epilepsy. And the third class of drugs is called neuroleptics.

It's very important to educate the family about the illness and to let them grieve. The last thing they want is for one of their children to have the illness. Then you can help them adapt and take part in the child's treatment. You also have to educate personnel at the school so that the expectation about the amount of work that the child can do is geared toward what the child can manage.



How well does medication control the disease?
Some kids do very well and become indistinguishable from other children as long as they take their medication regularly. The medication essentially has to be taken indefinitely, as it is in adults. Most who take it regularly will have fewer hospitalizations and suicide attempts, and they will be able to hold jobs better and have more stable personal relationships. For others, bipolar disorder is very difficult to treat, and it can be months of trying to find the right combination of treatments.



Are there strategies for helping teenagers stay on their medication?
Strategies have really not been formally researched and developed. This is a very important area for future research. For example, will there be Web-based programs the patients can go to? One thing that we find very helpful to do with adolescents is to grieve with them. The way parents have to mourn the loss of a child who's well, the children themselves have to mourn the loss of their former well self.

But grief hurts a millimeter less every day, so we usually can tell them that six months from now, it'll be more automatic just to take the medication and go about your other business.

What The Most Dangerous Job In The World Taught Me About Coping With Stress
By: Kevin Thompson



I just got through reading some troubling news in the New York Times this morning.

62% of employees now say that work-related stress leaves them overwhelmed and overtired.

And for many of us, who bring work home from the office, the problem is even worse.

So what’s going on?

Why are most of us so stressed?

I’ll tell you what a major part of the problem is… lack of job security.

I remember as I was growing up, my father only had two jobs. He was a high school teacher for the earlier part of his life, and later on he went into the real estate profession.

Two jobs, and they spanned his entire lifetime!

And the one career change he made was something he wanted to do. He didn’t make the change because he was losing his job as a teacher. In fact, the school district wanted him to stay.

But that’s a far cry from the way things are today. In fact, the days of job stability, and working for a single employer for your entire working career are long gone.

You’ll probably change jobs at least 11 times before you retire.

Downsizing, rapid business expansion and outsourcing are terms that we’re all too familiar with.

Before I got involved in the health industry and started my own indoor air quality business back in 1996, I’d already held 5 jobs in 5 completely different industries.

I worked as a telecommunications technician (in the Army), as a framer, on the green chain at 2 separate lumber mills, as a farm hand and finally as an Alaska fisherman for seven years (which was the hardest and most stressful job I ever had).

Now, you may be thinking to yourself, “You must’ve been a problem employee”.

But the fact is, nothing could be further from the truth.

I was in fact a model employee for every company I worked for, and never left a single employer on bad terms.





For example…

I began working as an Alaska fisherman in 1988. My main motivation for doing this was the money. Quite honestly, that’s the only reason I took the job.

And if you’ve ever seen that movie “The Perfect Storm” or watched those shows on the discovery channel, you have an idea of what it’s like to fish in Alaska.

My own story isn’t much different and it taught me why being an Alaska Fisherman is know as “The Most Dangerous Job In The World”.

The winter of 1995 had been an especially bad winter in Alaska. Fishing boats and fishermen's lives were being claimed by the Bering Sea almost weekly.

I was working on the outside deck after dark and we were in an unbelievable storm. It was the worst I'd seen in my 7 years of fishing. The kind of thing you only see in the movies.

I was scared to death!

But I had my own way of dealing with my fears. I'd never look out at the horizon when we were in a storm like this because I didn't want to see the big picture. I didn't want to know how high the waves really were. So I'd just concentrate on my job, which was to get all the fish onto the boat. As long as I did my job, and didn't look up, I could almost convince myself that the storm wasn't that bad.

While this certainly wasn’t the best way to deal with stress, at the time, it was the only way I knew how.

As always, the captain was in the wheelhouse driving the boat. His job was to keep an eye on me and watch for the dangerous rogue waves that would come out of nowhere and slam into us broadside. He'd tell me if I was in any real danger.

And then it happened!

I heard the captain's thundering voice over the intercom system.

Kevin! Hit the deck!

Before I could react, I was buried under a wall of water that hurled me all the way across the deck of the boat, face first into the railing on the other side.

When the water settled, and I realized what had happened, my immediate thought was, "Thank God I'm still on the boat" The impact had knocked out my front teeth and caused serious facial damage, but at least I was still alive, and on the boat.

If that wave would have lifted me just a few inches higher, I would have been thrown right over the top of the railing into the freezing waters of the Bering Sea. And there's one thing I knew for sure. In a storm like that, there's no way in hell the captain would have got that boat turned around in time to save me. I would have died right then and there.

It was at that moment I decided my life as an Alaska Fisherman was over.

While it was a great experience, I’ve never regretted my decision to leave the fishing industry. I just didn’t want to deal with that much stress in my life.

Decades of research has linked stress to everything from heart attacks and stroke to diabetes and a weakened immune systems, and none of us want to deal with that.

I’ve since found much better ways to deal with stress, and you can too by using the resources on this site.

-----------------------------------------

Kevin Thompson is a national authority on indoor air quality and health issues. His free Health Articles & News Update service gives you instant access to the world's most respected and sought after health experts in 70 categories, including Men’s Health, Women’s Health and Children’s Health just to name a few. Find out how this free service is changing people's lives and how you too can live a longer, healthier and more prosperous lifestyle... beginning today!

How To Destress Your Life Naturally
By: DAVE WOYNAROWSKI, M.D.
The World's Top Anti-Aging Specialist


What would you say if I told you that a lot of today's stresses are not environmental!

You'd probably say, "What are you talking about! If so and so wasn't doing this and my boss wasn't doing that and he kids listened better I would be a lot calmer!"

Well that is probably true, but your ancestors had to deal with disease starvation and wild animals which had to be very stressful!

I don't think A.D.D. and Chronic Fatigue and Fibromyalgia were survival advantages!

My point is this: As I've said before Food is the most powerful drug ever invented. And the biggest missing in our diets if Omega 3 fatty acids.

With the proper amount of fish Oil Omega 3 fatty acids in your body you will notice you are a lot calmer and much more able to handle stress creatively!

A while back I talked about the effects of stress on longevity and health. All of it was bad!

Well, I have recently uncovered some additional evidence that Omega 3 fatty acids are needed for us to respond properly to stress.

And I mean serious stress, like the kind our ancestors faced, AND the version of it we face today!

Undoubtedly this is how our ancestors survived the tremendous stresses in their lives.





In all of the cardiac studies with fish oil it shows there is an inverse relationship between fish oil intake and death and development of heart attack in humans.

We have talked in the past about all kinds of reasons for this: the blood thinning effect of fish oil via platelets, the direct anti-inflammatory effect of fish oil on the formation of clogged heart arteries.

The latest research suggests that Fish Oil has adaptogenic properties with regards to the human response to stress.

This includes a direct effect on a very primitive part of the human brain called the brain stem. It is from this area that nervous discharges happen.

One type of nervous discharge is called "sympathetic".

This funny name refers to the type of nervous discharge that causes blood vessels to tighten blood pressure to go up and people to get anxious and stressed out.

It also leads to increased cortisol which is the hormonal equivalent of suicide by stress!

Fish oil attenuates this type of discharge and allows the body to respond in a graded sensible manner instead of a ballistic blast.

Most of you are aware of fish Oil's effects on the brain as well. I've referenced many studies in the past on depression and behavioral modification with Fish Oil via serotonin and dopamine, brain chemicals.

Another very cool and very healthy thing happens when adequate fish oil is present in the system.

The body starts using fat preferentially as a fuel during times of mental and physical stress.

So there you have it! Improve your brain chemistry, buffer your body's ability to handle both mental and physical stress, burn more fat, reduce cortisol and the illness it is associated with including aging!

What more could you ask for! Make sure you go to the site and order as the winter flu season comes upon us and take advantage of the beneficial immune effects that fish Oil can also give you!

Breast Augmentation: A Public Health Perspective


By: Diana Zuckerman, PhD

More than 150,000 women had breast augmentation surgery last year; an all-time high. At the same time, the number of teenagers who choose breast implants has more than doubled in the last two years.

And yet, the controversy about breast implants still rages. As is often the case when the media covers medical issues, there are experts on all sides of this issue, and the consumer is left totally confused.

As a Congressional investigator in the early 1990s, I had access to all published and unpublished studies of breast implants, and was appalled to learn that almost one million women had breast implants, but they had never been objectively evaluated in either clinical trials or epidemiological research. That situation has changed. After the FDA started restricting access to silicone gel breast implants, the implant manufacturers started to fund research in an effort to prove that they were safe.

As a scientist trained in psychology and epidemiology, I have studied both the desire for implants and the possible physical risks. Despite all the controversy and media coverage about breast implants, there are surprisingly few studies on the psychological benefits of implants, the local complications caused by breast implants, or the long-term risks. Instead, there is a great deal of misinformation in the media, and many women make the decision to get breast implants with unrealistic expectations about how it will change their lives, little awareness of the financial consequences, and without the resources to cope if problems do occur.



Breast Implants and Self-Image
Plastic surgeons claim that breast implants have a very positive impact on a patient’s self-image. It would be easy to study this objectively, by evaluating women’s self-esteem and body image before, after, and several years after getting breast implants. No such study has ever been conducted.

Surveys indicate that when plastic surgeons ask their patients if they are satisfied, most say that they are. However, that is not an objective way to study the impact on breast implants. There is no doubt that some women are very satisfied with their breast implants, but any evaluation of patient satisfaction should be conducted by someone other than the plastic surgeons or their staff. If you want honest and accurate answers, it is important for patients to feel that their answers are anonymous. Since implants are a lifetime commitment, it is also important to study them several years later, since that is when problems become more likely.

From a psychological point of view, improving one’s appearance, with plastic surgery or other means, can help a person feel better about himself or herself. On the other hand, there are individuals who feel unattractive because of a particular physical shortcoming, who then “solve” that problem, and then focus on a different shortcoming. There are other potential problems specific to implants: a woman who changes her appearance by getting breast implants may find that men treat her so differently that she feels uncomfortable. If the implants seem obvious (for example, because of the swooshing sound of saline, hardness from capsular contracture, or because they don’t feel the same as natural breasts) she may become more self-conscious rather than self-confident.



Are Breast Implants Approved by the FDA?
It may surprise you to learn that there are almost no published studies of the safety of saline breast implants, and that no breast implants were ever approved by the FDA until a few months ago. In May 2000, for the first time, the FDA approved several styles of saline breast implants made by two manufacturers, Mentor and McGhan. The FDA decided to give women the choice of buying implants even though FDA advisors expressed a great deal of concern about the complications experienced by many women with implants. The FDA did not approve saline implants made by other manufacturers, and did not approve some of the styles of implants previously sold by either Mentor or McGhan. That means that many women are walking around today with implants that never were approved by the FDA and probably never will be.

Saline breast implants are made with silicone outer shells with saline inside. The implants, commonly called “silicone implants,” have the same kind of silicone outer shells, with silicone gel on the inside.

No type of silicone gel breast implant has ever been approved by the FDA. When the FDA reviewed the safety research in 1991, they determined that the studies did not prove that implants were safe. The sale of silicone gel breast implants was therefore restricted to mastectomy patients, patients with breast deformities, and any augmentation patient who had a broken silicone gel implant that she wanted to replace. All of those women are required to participate in a study of the health risks. A small number of first-time augmentation patients were recently included in these studies.



Saline Implants
FDA approval of some Mentor and McGhan saline breast implants is based on studies that are not published. For detailed information, check out the FDA Web site or the summary on the Web site of the National Center for Policy Research for Women and Families.

The manufacturers studied local complications such as pain, implant rupture, and the rate of subsequent surgery and implant removal. Mentor reported that 43 percent of the augmentation patients in their study experienced local complications within the first three years, including:

* asymmetry, scarring, or wrinkling (32 percent)
* needing additional surgery (13 percent)
* severe capsular contracture (10 percent)
* implant removal (8 percent)

Even more women (60 percent) with McGhan implants reported at least one serious complication in the almost four years of that study. In the first three years, McGhan patients experienced the following:

* asymmetry, scarring, or wrinkling (27 percent)
* needing additional surgery (21 percent)
* severe capsular contracture (9 percent)
* had at least one implant removed (8 percent)

The complication rates were even higher for patients who got new breast implants to replace previous implants, and higher still for women getting implants for reconstruction after a mastectomy.

If these complication rates sounds very high to you, you’re not alone. The FDA decision to approve saline implants has been questioned by members of Congress because one of the manufacturing companies is under a criminal investigation and because the FDA did not require long-term studies or studies of whether saline breast implants cause serious diseases. Long-term research is essential, because many of the implant patients who have had problems, complain of systemic diseases that developed years after getting their implants.

Instead, the FDA apparently relied on studies that had been reviewed by the Institute of Medicine, which did not find a significant increase in systemic diseases among implant patients. However, the Institute of Medicine only reviewed studies that had been conducted previously, and these studies were not conclusive.






Silicone Gel Implants
The Institute of Medicine report primarily focused on silicone gel breast implants, and found no statistically significant relationship to systemic disease in most of them. However, several studies found an increased risk of connective tissue diseases, although the risk was not always statistically significant. These trends can mean several things:

* Illness could occur by chance (in other words, whether or not the person has implants)

* The sample could be too small to detect a real risk (this is especially likely when rare diseases like scleroderma (connective tissue disorder) are studied)

* The study is not well designed—for example, most of the studies include women who had implants for a few months or years, which is probably too short a period of time to develop connective tissue disease or cancer.



Whether or not silicone gel implants cause systemic disease, a new FDA study shows that they break more quickly than has been acknowledged. The new FDA study, published in September, 2000, showed that many women with silicone gel implants walk around with broken and leaking implants without knowing it. Using magnetic resonance imaging (MRI), researchers determined that almost half (48 percent) of the women who had silicone gel-filled implants for only six to ten years had at least one ruptured implant, even though they didn’t know it. Even more of the women (79 percent) who had gel-filled implants for 11 to 15 years had at least one ruptured implant. What was surprising was that the women had not realized the implants were broken and had not sought any medical care. Since this study excluded any women who had already reported implant problems or removal, the actual breakage rate is even higher.

Even more worrisome is that more than one in five of women had silicone gel “migrating” away from the broken implant capsule. The long-term risks of migrating silicone are unknown, but there are studies documenting serious health risks and fatalities when liquid silicone migrates to vital organs. Since silicone gel can break down to liquid form, this is a serious concern, especially since these women were not aware of what was happening and only found out because they were randomly selected for a study.



What Are the Local Complications of All Implants?
There are some known risks of implants that are true for either saline-filled or silicone gel-filled implants:

All surgery for breast implants, whether silicone gel or saline, has risks. These include the risk of infection, hematoma (blood or tissue fluid collecting around an implant), the risk that one or both of the implants will have to be removed (requiring additional surgery), and the potential costs of repeated surgeries if the implants are replaced.

All breast surgery, including implants, can interfere with a woman’s ability to breast-feed a baby. Women with implants are less likely to be able to nurse than women who have not had breast surgery.

All breast implants will eventually break, but it is not known how many years the breast implants that are currently on the market will last. As shown in the recent FDA study, most implants last seven to 12 years, but some break during the first few months or years, and some last more than 15 years.

The most common complaint is capsular contracture, which occurs when a woman's body reacts to the “foreign body” by forming a capsule of scar tissue around the implants that can become too tight. If that happens, the breasts can become very hard, misshapen, and painful as a result, often requiring surgery or removal. The appearance is common among actresses and models, who sometimes look like they have two balls attached to their chests instead of natural breasts. The result is especially unattractive if one breast has contracture and the other doesn’t, or if the contracture causes the breast to feel very hard or to change in shape. View a photo of capsular contracture on the FDA Web site.

Although the epidemiological studies have not proved that systemic disease is caused by breast implants, several European studies have indicated that breast surgery (whether for breast implants or to reduce the size of breasts) may be associated with an increased risk of connective tissue disease or rheumatism. If these disorders, which include diseases such as scleroderma and fibromyalgia (a syndrome characterized by chronic fatigue and body aches and pains), are related to breast surgery, all women with implants would be at increased risk, regardless of whether the implants are filled with saline or silicone gel. Since women with implants often have multiple surgeries, the risks of systemic illness are potentially increased even further.

All breast implants interfere with mammography, because implants can obscure the view of a tumor. Implants, therefore, have the potential to delay the diagnosis of breast cancer. Although specially trained technicians can perform mammography in ways that minimize the interference of the implants, not all women have access to a mammography technician with this expertise. Unfortunately, even with expert technicians, about 30 percent of the breast will still be obscured. Experts estimate that 20,000 to 40,000 women who already have implants will have a delayed diagnosis of breast cancer because of their implants.

Although there are no long-term safety studies of saline implants, it is assumed that they are safer than silicone gel implants because if they break, they can be more easily removed. In contrast, silicone gel can be very difficult or even impossible to completely remove from the body once an implant has ruptured. In addition, it is not always obvious that a silicone gel implant has broken, and the gel can migrate slowly over time into various parts of the body. However, there is research evidence that bacteria and mold can grow in a saline-filled implant, and nobody has studied what happens when the implant breaks in a woman’s body. In addition, even saline implants can leak small amounts of silicone or platinum into the body, which come from the outer shell (the “bag” that holds the saline) of the implant. The long-term health risks of those leaks are unknown.



Financial and Insurance Concerns
Breast augmentation usually costs $5,000 to $7,000 and many physicians will sell the procedure on the installment plan. However, the initial cost is small compared to the lifetime costs, even for women who like their implants.

Since implants can break at any time, and are almost assured of breaking within seven to 12 years, a woman needs to consider the lifetime expense of additional surgery and replacement. Although unusual, some implants break within a few days, weeks, or months of surgery. Some implant manufacturers promise to replace the implants for free, but the expense of the implant may be a small percentage of the total cost of augmentation. Some doctors also promise to provide their replacement services for free, but that does not include the cost of the medical facility, anesthesiologist, and so on.

Augmentation is almost never paid for by health insurance, so the costs of additional surgery can be very expensive. Women with implant problems can have many surgeries within a few years.

An even greater problem is that breast implants can make a woman uninsurable. While many insurance policies will merely exclude the implants, or the entire breast area from coverage (a terrible problem if the woman later gets breast cancer), some major insurance companies have decided to totally exclude any woman with breast augmentation from their policies.

The costs of removing a broken silicone gel implant are substantial. If the implant breaks and the silicone gel spills out, it can mix with the breast tissue and other tissue and be almost impossible to remove. Surgical efforts to remove broken gel implants can take hours and cost tens of thousands of dollars. In addition, a mastectomy may be necessary to remove the silicone in an otherwise healthy breast.



What Have I Got to Lose?
Many cosmetic changes are easy to undo. Breast implants are not. Once the skin and natural breast tissue have been stretched by breast implants, they will never look the same as they did before the implant surgery. Most plastic surgeons try to persuade their patients to replace a problem implant, warning them that they will be depressed by their appearance if they are taken out and not replaced. This should be of particular concern to parents who are considering implants for their daughters. If a 17-year-old dyes her hair, she can dye it back or grow it out. If she decides to get breast implants, it is a decision that will permanently change her body. If she wasn’t satisfied with the size of her breasts before implants, imagine how she will feel to have breasts that are just as small and also sagging.



Why Weren’t Implants Studied Before They Were Sold to Women?
With all the problems and unanswered questions about breast implants, the obvious question is “Why weren’t implants studied first and improved before selling them to women across the country?”

The FDA did not have the authority to regulate any kinds of implants or medical devices until 1976. Implants had been sold since the 1960s, so they were allowed to stay on the market until the FDA reviewed them. Meanwhile, there was a substantial backlog of products that the FDA needed to review, and cosmetic products like breast implants were not a priority. Unfortunately, the manufacturers did not conduct long-term studies until the FDA required them.



Conclusion
The more than one million women who have breast implants are, without their realizing it, part of a natural “study” to learn what the risks are. Women deserve to be told what is known, and what is not known, before they make this decision. And, if a woman with implants complains of symptoms, she needs to find a plastic surgeon who has a reputation for helping women with implant problems.

Surgical Solutions to Obesity


With: Dr. Elliot Goodman

There are a host of medical problems associated with obesity. Stroke, diabetes, heart disease, and joint problems are just a few of the known consequences, and yet nearly one quarter of American adults are obese, and this number is rising. An estimated three to five percent of adult Americans are morbidly obese. For these individuals, medical problems, in addition to social and practical problems, are a near inevitability. Fortunately for some, the battle against obesity has a surgical weapon. It's called bariatric surgery.

Below, longtime general and bariatric surgeon, Dr. Elliot Goodman of the Montefiore-Einstein Center for Weight Reduction Surgery, talks about the procedure, and its effect on the physical and emotional lives of his patients.



First, could you tell us what bariatric surgery is, and who undergoes this procedure?
Bariatric surgery is the surgical treatment of severe obesity. And when we say severe, we mean anybody who is at least a hundred pounds overweight. People who undergo bariatric surgery have generally been obese for decades, and they most often have a history of childhood obesity.



What does the surgery entail?
In the surgery, we staple the stomach to make it much smaller, and we reroute food so that it bypasses the first few feet of intestines. We actually rearrange the anatomy and the physiology of the intestinal tract.



And what does this do to the body?
Well in addition to dramatically reducing the size of the stomach, the surgery also changes the hormonal condition of the patient. You're changing their sensitivity to insulin, you're changing their metabolism of iron and calcium and other nutrients.

And a lot of things which would otherwise get absorbed don't get absorbed. There are hormonal changes induced which suppress appetite. There are hormonal changes induced which increase the body's sensitivity to insulin, because most severely obese patients are resistant to insulin, which is why so many of them are diabetic. So it's one operation that has manifold effects on body metabolism.



Does this surgery actually treat diabetes in some cases?
Absolutely. I hear stories of patients who are on three or four different medications for diabetes, and a hundred units of insulin -- which is a big daily dose of insulin -- and within a few weeks they're off. They're off the medications even before they've lost a significant amount of weight. Also, people who have very high cholesterols will often see their cholesterol dipping down to normal. So these are some of the more dramatic effects of the operation.

Coronary artery disease and high blood pressure also respond well. It's great to see patients who may be on five, ten, twelve different medications, over time say, "Well, I dropped this medication," or, "I halved this dose." Within a year or two, they may be down to the bare minimum of medications.



I imagine that the surgery may also solve some of the more structural problems in the body, like joint pain?
Absolutely. People with aches and pains or degenerative joint disease are well served by this surgery.



Could you describe the experience of one patient who has responded well to the surgery?
Sure. I operated on a woman about a year and a half ago who was about three-hundred and fifty pounds overweight, and had been obese for most of her life.

She was only in her early forties, but was so big that she had to come into the office with a walker. She was unable to sit in any of the chairs even though we have fairly heavy-duty armless chairs, and she was too heavy to weigh in our office. Our scale goes up to five hundred pounds.



Did she describe to you her reasons for wanting the surgery?
She told me she couldn't work, couldn't fit into an armchair, and couldn't really go out anywhere. She said she could not take the bus, because she couldn't get up the stairs into the bus, or sit down in the bus. She didn't go out to shop because people would stare at her, whisper about her behind her back, or just blurt out obscenities at her.



Was bariatric surgery a last resort for her?
She'd been struggling with this for a very long time. She had tried everything else: diets, over the counter pills, and exercise, when she was younger and abler. And she had decided that if she didn't do anything at this point about her weight, having failed at everything else, her life expectancy was extremely limited. She wasn't sure whether she'd be around in a few more years. And I agreed that her weight was life-threatening.



What happened after the initial consultation?
First she was seen by our nutritionist, and then she was evaluated by one of the psychologists we use.



Why do you do a psychological evaluation?
Many reasons. A lot of patients who come in, perhaps at the suggestion of their own doctors, don't understand that this is a very big operation, and that it can occasionally go wrong, and that it can occasionally lead to complications, including death. This is not a tummy tuck, or liposuction. They need to understand the severity of the procedure, and the small chance of major complications.

Also, there are patients who may be depressed. If they are severely depressed, we'll often recommend that they defer surgery -- get the acute depression under control and then come back.

Binge eating is another problem among some of our prospective patients. They will respond to stress by eating, and will eat so much that they induce vomiting. If it persists after surgery, particularly in the early days post-surgery, binge eating can be very dangerous. After the surgery, patients have very small stomachs - approximately the size of an egg -- and if they try and stuff too much food into them, they can actually break down the surgical staples, causing a leak, which can be potentially fatal. So we need to weed these patients out.



How long, for our case study patient, did the whole testing period take?
The whole process took about six to eight weeks. After she was seen by the nutritionist and psychologist, she underwent a medical workup, just to make sure that she would be able to tolerate the operation and the anesthesia.



And the operation was successful?
Yes. The first big milestone was that we could actually weigh her. She dropped below five-hundred pounds. And then she was down to four-fifty, then four-hundred, and so on. Two or three months after her surgery, she was able to walk without the walker. Eventually she could sit down in our waiting room and get up without assistance. And her joint trouble began to subside.

She has a job now, and she's going back to school. Through the process of the operation, we were able to draw her back into the mainstream of life.



Do your patients keep in touch with you long after surgery?
Yes, the longevity of the relationship with the patients is quite remarkable. I don't think patients call their surgeons years after an operation to say, "Hey, three years ago you took out my gall bladder." But I get calls all the time from bariatric surgery patients. I bond with these people for years.

Just recently a patient called me up out of the blue and said, "You're the second person I've told that I'm pregnant." This was a patient who had been trying to get pregnant for ten years. But before the surgery she weighed three-hundred and fifty pounds, and she was essentially infertile.

What You Need To Know About Rhinoplasty: Nose Jobs


By: Jonathan Pontell, MD

Rhinoplasty, commonly referred to as a nose job, is any surgery done to change the shape of the nose. Rhinoplasty may be done for purely cosmetic reasons, for purely functional reasons such as to improve nasal breathing, or a combination of the two.

Because the nose has a very prominent central location on the face, the changes made with rhinoplasty can make a dramatic difference in a person’s appearance and lead to great increases in self-esteem and self-confidence.

Cosmetic rhinoplasty can change an almost infinite number of variations in nasal shapes. The goal of the surgery is to give an improved nasal contour that is in harmony with the rest of the face, while maintaining or improving nasal breathing. Most often, rhinoplasty is done to make a large nose smaller or a wide nose narrower, but occasionally the opposite is true.



The Consultation
Anyone considering rhinoplasty should see a board-certified facial plastic surgeon, otolaryngologist/head and neck surgeon (ENT), or general plastic surgeon for a consultation. The patient should seek out a surgeon who has extensive training and experience with both the cosmetic and functional aspects of this operation. It is advisable to ask to see a portfolio of before-and-after photographs of other rhinoplasties the surgeon has performed.

The consultation is an opportunity for me to listen to patients’ goals, to examine them, and to come up with a surgical plan. I examine the external and internal nose to determine what changes are possible. It is very helpful for patients to be able to clearly express what they do not like about their noses so I can determine if their goals are realistic. I also attempt to explore exactly what a patient’s motivation is for wanting nasal surgery. It is important to make sure that the patient has carefully thought about the decision to have surgery and that the desire is not based on a whim, to please someone else, or because of a recent life-changing event, such as a divorce.

During the consultation, I use computer imaging to show patients the changes that are possible. Computer imaging is a powerful tool that is useful in establishing clear communication between the patient and myself as to what the surgical goal should be. It is important to note, however, that the computer-simulated photographs are only an estimation of the desired outcome. Although the actual result of surgery usually closely approximates the computer-simulated images, no surgeon can guarantee to what extent a complete match will occur.



Assessing the Face
When examining the patient, I look at the entire face to determine what changes are needed to create the most aesthetically pleasing result. I take into account the patient’s ethnic background, bony and cartilaginous anatomy, skin thickness, general health status, and age. Female patients should be at least 15 to 16 years old and males should be 16 to 17 years old—ages at which the vast majority of nasal growth has been completed. Nasal surgery done prior to the completion of nasal growth may result in developmental abnormalities of the nose.

At the consultation I may also suggest that the patient undergo another procedure in combination with the rhinoplasty to maximize facial harmony and balance. The most common procedure done in combination with rhinoplasty is chin augmentation, but cheek augmentation and chin reduction may also be done in combination with rhinoplasty.





Surgery location
The rest of my consultation includes a discussion of the different locations at which I perform surgery. These locations include hospital operating rooms, surgicenters, and my office operating rooms. Patients should be sure that anesthesia given in an office operating room is provided by a licensed anesthesiologist or nurse anesthetist. Also, all of the same monitoring equipment present in a hospital operating room, such as EKG machines and blood-oxygen level monitors, should be in the office for your surgery.

Patients are usually given local anesthesia with sedation to place them in a comfortable drowsy state, but they remain awake. The other option is general anesthesia where the patient goes to sleep fully. The first option is safer and has less postoperative nausea and a quicker recovery.



Rhinoplasty Techniques
There is a multitude of variations in rhinoplasty techniques. The technique used depends on what type of problem exists and also on the individual surgeon’s preference. Most of the incisions are placed inside the nose, but some surgeons employ a technique called open or external rhinoplasty, in which a small incision is placed in the columella, which is the bridge of skin separating the two nostrils. This incision, when connected with the intranasal incisions, allows better exposure of the nasal anatomy than the more traditional techniques. The benefits of improved exposure are better symmetry and more sophisticated ways of altering the nasal anatomy, which I believe lead to better results. Also, occasionally, incisions are placed at the base of the nostrils for nostril narrowing.

Bone restructuring
Once the surgical exposure of the cartilage and bones of the nose is accomplished, many different maneuvers are used to modify them.

Nasal bones and cartilage may be shaved down if too prominent, repositioned if out of alignment or too wide, or added to if deficient. Nasal tip cartilages are often reduced in size and sutures are placed to narrow and refine them.

Often, in the case of twisted, deviated, or wide noses, cuts will be made in the nasal bones to allow them to be repositioned. Deficiencies in the nasal structure are replaced with grafts of cartilage from the nasal septum, ear or rib, or bone from the skull, rib, or hip. Nasal deficiencies may also be replaced with synthetic materials such as Gore-TexTM or SilasticTM. The advantage of using synthetic materials for nasal augmentation is that no further surgical procedures are needed to harvest these materials. The implant is simply removed from a sterile package, carved to the proper shape and implanted. The disadvantage of synthetic implants is that they can become infected or lead to thinning of the skin and eventual exposure of the implant necessitating implant removal. Implants from the patient’s own cartilage or bone almost never cause any of these problems.

After all of the modifications to the nasal structure are completed the incisions are closed and a cast is usually applied. Occasionally, depending on exactly what type of procedure was done, VaselineTM gauze or a sponge dressing may be placed inside the nose for one to two days.



What to Expect After Surgery
After surgery, patients usually have minimal pain, which is easily controlled with pain medication. The degree of swelling and bruising depends on how extensive the surgery was. If mobilizing and repositioning the nasal bones was not part of the surgery then swelling and bruising around the eyes is usually minimal. If the nasal bones were repositioned, swelling and bruising around the eyes may be significant, but is usually gone in seven-to-ten days. Most patients feel comfortable going out in public by this time. Some surgeons give steroid medications for a few days after the surgery in an attempt to minimize swelling as much as possible. By six weeks, the majority of swelling of the nose is gone, but it often takes many months for the final amounts of swelling to disappear.

Sleeping
It is helpful for the patient to sleep with his or her head elevated on a few pillows for the first week to allow gravity to aid in reducing the swelling as quickly as possible. The cast is usually removed after one week and any external sutures that were used are also removed around this time. When the cast is removed, the patient will get some idea of how the nose will look, but during the next few weeks to months, significant changes will occur with healing and the disappearance swelling.

Post-surgery activities
Patients are told not to engage in any strenuous activities for the first two weeks after surgery that could lead to nose bleeds, and to avoid direct sun exposure for the first few months, which would lead to swelling of the nose. Also, it is advisable for the first six weeks to avoid activities that could lead to the nose being hit or bumped. Patients who wear glasses may be advised to tape their glasses to their foreheads for a few weeks if their nasal bones were repositioned in order to avoid the weight of the glasses displacing the nasal bones.



Surgical Risks
All surgery is associated with risks. For patients who do not have significant medical problems, the risks are minimal. Any surgery can result in an infection, a bleeding problem, or an adverse reaction to the anesthesia medications. Again, these are extremely rare occurrences. Poor healing, the development of scar tissue under the skin, nasal contour irregularities and postoperative nasal breathing problems are also possible occurrences. All of these complications are treatable.



Surgical Costs
The surgical fee for rhinoplasty varies from doctor to doctor and may depend on how extensive the surgery will be, but a range of $3,000 to $5,000 is typical. Insurance may cover the entire cost of the surgery including anesthesia and operating room fees if the surgery is done for functional and not cosmetic reasons. Rhinoplasty, for a combination of functional and cosmetic reasons, may be partially covered, but surgery for purely cosmetic reasons is not covered by insurance.



Conclusion
The latest techniques used in rhinoplasty allow surgeons to give patients natural, aesthetically pleasing results with good nasal function. Patients with the proper self-motivation and realistic expectations for the surgery are usually very pleased.

Breast Augmentation: A Public Health Perspective


By: Diana Zuckerman, PhD

More than 150,000 women had breast augmentation surgery last year; an all-time high. At the same time, the number of teenagers who choose breast implants has more than doubled in the last two years.

And yet, the controversy about breast implants still rages. As is often the case when the media covers medical issues, there are experts on all sides of this issue, and the consumer is left totally confused.

As a Congressional investigator in the early 1990s, I had access to all published and unpublished studies of breast implants, and was appalled to learn that almost one million women had breast implants, but they had never been objectively evaluated in either clinical trials or epidemiological research. That situation has changed. After the FDA started restricting access to silicone gel breast implants, the implant manufacturers started to fund research in an effort to prove that they were safe.

As a scientist trained in psychology and epidemiology, I have studied both the desire for implants and the possible physical risks. Despite all the controversy and media coverage about breast implants, there are surprisingly few studies on the psychological benefits of implants, the local complications caused by breast implants, or the long-term risks. Instead, there is a great deal of misinformation in the media, and many women make the decision to get breast implants with unrealistic expectations about how it will change their lives, little awareness of the financial consequences, and without the resources to cope if problems do occur.



Breast Implants and Self-Image
Plastic surgeons claim that breast implants have a very positive impact on a patient’s self-image. It would be easy to study this objectively, by evaluating women’s self-esteem and body image before, after, and several years after getting breast implants. No such study has ever been conducted.

Surveys indicate that when plastic surgeons ask their patients if they are satisfied, most say that they are. However, that is not an objective way to study the impact on breast implants. There is no doubt that some women are very satisfied with their breast implants, but any evaluation of patient satisfaction should be conducted by someone other than the plastic surgeons or their staff. If you want honest and accurate answers, it is important for patients to feel that their answers are anonymous. Since implants are a lifetime commitment, it is also important to study them several years later, since that is when problems become more likely.

From a psychological point of view, improving one’s appearance, with plastic surgery or other means, can help a person feel better about himself or herself. On the other hand, there are individuals who feel unattractive because of a particular physical shortcoming, who then “solve” that problem, and then focus on a different shortcoming. There are other potential problems specific to implants: a woman who changes her appearance by getting breast implants may find that men treat her so differently that she feels uncomfortable. If the implants seem obvious (for example, because of the swooshing sound of saline, hardness from capsular contracture, or because they don’t feel the same as natural breasts) she may become more self-conscious rather than self-confident.



Are Breast Implants Approved by the FDA?
It may surprise you to learn that there are almost no published studies of the safety of saline breast implants, and that no breast implants were ever approved by the FDA until a few months ago. In May 2000, for the first time, the FDA approved several styles of saline breast implants made by two manufacturers, Mentor and McGhan. The FDA decided to give women the choice of buying implants even though FDA advisors expressed a great deal of concern about the complications experienced by many women with implants. The FDA did not approve saline implants made by other manufacturers, and did not approve some of the styles of implants previously sold by either Mentor or McGhan. That means that many women are walking around today with implants that never were approved by the FDA and probably never will be.

Saline breast implants are made with silicone outer shells with saline inside. The implants, commonly called “silicone implants,” have the same kind of silicone outer shells, with silicone gel on the inside.

No type of silicone gel breast implant has ever been approved by the FDA. When the FDA reviewed the safety research in 1991, they determined that the studies did not prove that implants were safe. The sale of silicone gel breast implants was therefore restricted to mastectomy patients, patients with breast deformities, and any augmentation patient who had a broken silicone gel implant that she wanted to replace. All of those women are required to participate in a study of the health risks. A small number of first-time augmentation patients were recently included in these studies.



Saline Implants
FDA approval of some Mentor and McGhan saline breast implants is based on studies that are not published. For detailed information, check out the FDA Web site or the summary on the Web site of the National Center for Policy Research for Women and Families.

The manufacturers studied local complications such as pain, implant rupture, and the rate of subsequent surgery and implant removal. Mentor reported that 43 percent of the augmentation patients in their study experienced local complications within the first three years, including:

* asymmetry, scarring, or wrinkling (32 percent)
* needing additional surgery (13 percent)
* severe capsular contracture (10 percent)
* implant removal (8 percent)

Even more women (60 percent) with McGhan implants reported at least one serious complication in the almost four years of that study. In the first three years, McGhan patients experienced the following:

* asymmetry, scarring, or wrinkling (27 percent)
* needing additional surgery (21 percent)
* severe capsular contracture (9 percent)
* had at least one implant removed (8 percent)

The complication rates were even higher for patients who got new breast implants to replace previous implants, and higher still for women getting implants for reconstruction after a mastectomy.

If these complication rates sounds very high to you, you’re not alone. The FDA decision to approve saline implants has been questioned by members of Congress because one of the manufacturing companies is under a criminal investigation and because the FDA did not require long-term studies or studies of whether saline breast implants cause serious diseases. Long-term research is essential, because many of the implant patients who have had problems, complain of systemic diseases that developed years after getting their implants.

Instead, the FDA apparently relied on studies that had been reviewed by the Institute of Medicine, which did not find a significant increase in systemic diseases among implant patients. However, the Institute of Medicine only reviewed studies that had been conducted previously, and these studies were not conclusive.







Silicone Gel Implants
The Institute of Medicine report primarily focused on silicone gel breast implants, and found no statistically significant relationship to systemic disease in most of them. However, several studies found an increased risk of connective tissue diseases, although the risk was not always statistically significant. These trends can mean several things:

* Illness could occur by chance (in other words, whether or not the person has implants)

* The sample could be too small to detect a real risk (this is especially likely when rare diseases like scleroderma (connective tissue disorder) are studied)

* The study is not well designed—for example, most of the studies include women who had implants for a few months or years, which is probably too short a period of time to develop connective tissue disease or cancer.



Whether or not silicone gel implants cause systemic disease, a new FDA study shows that they break more quickly than has been acknowledged. The new FDA study, published in September, 2000, showed that many women with silicone gel implants walk around with broken and leaking implants without knowing it. Using magnetic resonance imaging (MRI), researchers determined that almost half (48 percent) of the women who had silicone gel-filled implants for only six to ten years had at least one ruptured implant, even though they didn’t know it. Even more of the women (79 percent) who had gel-filled implants for 11 to 15 years had at least one ruptured implant. What was surprising was that the women had not realized the implants were broken and had not sought any medical care. Since this study excluded any women who had already reported implant problems or removal, the actual breakage rate is even higher.

Even more worrisome is that more than one in five of women had silicone gel “migrating” away from the broken implant capsule. The long-term risks of migrating silicone are unknown, but there are studies documenting serious health risks and fatalities when liquid silicone migrates to vital organs. Since silicone gel can break down to liquid form, this is a serious concern, especially since these women were not aware of what was happening and only found out because they were randomly selected for a study.



What Are the Local Complications of All Implants?
There are some known risks of implants that are true for either saline-filled or silicone gel-filled implants:

All surgery for breast implants, whether silicone gel or saline, has risks. These include the risk of infection, hematoma (blood or tissue fluid collecting around an implant), the risk that one or both of the implants will have to be removed (requiring additional surgery), and the potential costs of repeated surgeries if the implants are replaced.

All breast surgery, including implants, can interfere with a woman’s ability to breast-feed a baby. Women with implants are less likely to be able to nurse than women who have not had breast surgery.

All breast implants will eventually break, but it is not known how many years the breast implants that are currently on the market will last. As shown in the recent FDA study, most implants last seven to 12 years, but some break during the first few months or years, and some last more than 15 years.

The most common complaint is capsular contracture, which occurs when a woman's body reacts to the “foreign body” by forming a capsule of scar tissue around the implants that can become too tight. If that happens, the breasts can become very hard, misshapen, and painful as a result, often requiring surgery or removal. The appearance is common among actresses and models, who sometimes look like they have two balls attached to their chests instead of natural breasts. The result is especially unattractive if one breast has contracture and the other doesn’t, or if the contracture causes the breast to feel very hard or to change in shape. View a photo of capsular contracture on the FDA Web site.

Although the epidemiological studies have not proved that systemic disease is caused by breast implants, several European studies have indicated that breast surgery (whether for breast implants or to reduce the size of breasts) may be associated with an increased risk of connective tissue disease or rheumatism. If these disorders, which include diseases such as scleroderma and fibromyalgia (a syndrome characterized by chronic fatigue and body aches and pains), are related to breast surgery, all women with implants would be at increased risk, regardless of whether the implants are filled with saline or silicone gel. Since women with implants often have multiple surgeries, the risks of systemic illness are potentially increased even further.

All breast implants interfere with mammography, because implants can obscure the view of a tumor. Implants, therefore, have the potential to delay the diagnosis of breast cancer. Although specially trained technicians can perform mammography in ways that minimize the interference of the implants, not all women have access to a mammography technician with this expertise. Unfortunately, even with expert technicians, about 30 percent of the breast will still be obscured. Experts estimate that 20,000 to 40,000 women who already have implants will have a delayed diagnosis of breast cancer because of their implants.

Although there are no long-term safety studies of saline implants, it is assumed that they are safer than silicone gel implants because if they break, they can be more easily removed. In contrast, silicone gel can be very difficult or even impossible to completely remove from the body once an implant has ruptured. In addition, it is not always obvious that a silicone gel implant has broken, and the gel can migrate slowly over time into various parts of the body. However, there is research evidence that bacteria and mold can grow in a saline-filled implant, and nobody has studied what happens when the implant breaks in a woman’s body. In addition, even saline implants can leak small amounts of silicone or platinum into the body, which come from the outer shell (the “bag” that holds the saline) of the implant. The long-term health risks of those leaks are unknown.



Financial and Insurance Concerns
Breast augmentation usually costs $5,000 to $7,000 and many physicians will sell the procedure on the installment plan. However, the initial cost is small compared to the lifetime costs, even for women who like their implants.

Since implants can break at any time, and are almost assured of breaking within seven to 12 years, a woman needs to consider the lifetime expense of additional surgery and replacement. Although unusual, some implants break within a few days, weeks, or months of surgery. Some implant manufacturers promise to replace the implants for free, but the expense of the implant may be a small percentage of the total cost of augmentation. Some doctors also promise to provide their replacement services for free, but that does not include the cost of the medical facility, anesthesiologist, and so on.

Augmentation is almost never paid for by health insurance, so the costs of additional surgery can be very expensive. Women with implant problems can have many surgeries within a few years.

An even greater problem is that breast implants can make a woman uninsurable. While many insurance policies will merely exclude the implants, or the entire breast area from coverage (a terrible problem if the woman later gets breast cancer), some major insurance companies have decided to totally exclude any woman with breast augmentation from their policies.

The costs of removing a broken silicone gel implant are substantial. If the implant breaks and the silicone gel spills out, it can mix with the breast tissue and other tissue and be almost impossible to remove. Surgical efforts to remove broken gel implants can take hours and cost tens of thousands of dollars. In addition, a mastectomy may be necessary to remove the silicone in an otherwise healthy breast.



What Have I Got to Lose?
Many cosmetic changes are easy to undo. Breast implants are not. Once the skin and natural breast tissue have been stretched by breast implants, they will never look the same as they did before the implant surgery. Most plastic surgeons try to persuade their patients to replace a problem implant, warning them that they will be depressed by their appearance if they are taken out and not replaced. This should be of particular concern to parents who are considering implants for their daughters. If a 17-year-old dyes her hair, she can dye it back or grow it out. If she decides to get breast implants, it is a decision that will permanently change her body. If she wasn’t satisfied with the size of her breasts before implants, imagine how she will feel to have breasts that are just as small and also sagging.



Why Weren’t Implants Studied Before They Were Sold to Women?
With all the problems and unanswered questions about breast implants, the obvious question is “Why weren’t implants studied first and improved before selling them to women across the country?”

The FDA did not have the authority to regulate any kinds of implants or medical devices until 1976. Implants had been sold since the 1960s, so they were allowed to stay on the market until the FDA reviewed them. Meanwhile, there was a substantial backlog of products that the FDA needed to review, and cosmetic products like breast implants were not a priority. Unfortunately, the manufacturers did not conduct long-term studies until the FDA required them.



Conclusion
The more than one million women who have breast implants are, without their realizing it, part of a natural “study” to learn what the risks are. Women deserve to be told what is known, and what is not known, before they make this decision. And, if a woman with implants complains of symptoms, she needs to find a plastic surgeon who has a reputation for helping women with implant problems.

Sports Doping: What Should Parents Know?


By: Donald E. Greydanus, MD

Using chemicals in the hopes of improving athletic performance is nothing new. If you were an athlete in the Greek Olympic days, your coach might have suggested you try various mushrooms to gain a competitive advantage. In the present, the pressure to excel and to win is stronger than ever. From playgrounds to professional arenas, athletes today are tempted by a wide variety of substances that promise to boost performance, appearance, and overall health. We call this phenomenon sports doping. It is important that the parents of young athletes understand how prevalent and potentially dangerous this situation is.

There is much yet to be learned about the effects and side effects of performance enhancing chemicals, especially on children.

Because these drugs are so widely available, and because many famous athletes are known users, some parents assume that drugs are OK for their children to use, especially since many famous athletes are known to be users and abusers of various chemicals.

Parents often ask me why we know so little about these drugs. In truth, well-conceived, scientific studies are often done only on adult males who are involved with competitive athletics.

It is not easy to clearly relate a side effect to a specific chemical taken, since there are many factors that may be involved for each individual. Further, many of these chemicals are called nutrients and are readily available in nutrition stores. Since some of these substances are not classified as drugs, they are not under the control of the Federal Drug Administration. The manufacturers and sellers of these nutrients are free to make extravagant and unproven claims about their products. Unfortunately, it is our children who may suffer the negative effects of these products while the makers and sellers reap the profit. ‘Buyer Beware!’ is certainly the right message for anyone who wants to become, or remain, a sports doper. I will now provide an overview of some of the most common performance enhancing substances used by children.



Creatine
Creatine has become a very popular product with teen athletes. Annual sales total over 200 million dollars. It is advertised as a natural product that will provide larger, more powerful muscles. Creatine is actually an essential amino acid, meaning that it is a necessary nutrient for human beings. It can be produced by the body from other amino acids, such as arginine and glycine. It may also be provided in the diet—creatine occurs naturally in fish, milk, meat, and other foods.

Studies performed on adult athletes indicate that creatine may increase muscle mass, probably due to the retention of fluid. More importantly, the athlete who is undergoing intense exercise training and taking creatine may increase his or her power for short-term sports action, such as sprinting and playing football. Thus, it is very popular with high school football players and track athletes. Some coaches, trainers, and even parents have pushed this product on their athletes in the hope of producing winners.

So what is wrong with taking creatine? Well, creatine has received very little scientific study. We do not know anything about its long-term effects. We do not know what doses are best and what is excessive. The doses kids take are varied and often mixed with other drugs or chemicals that have their own unknown effects. The stores that sell creatine have no idea how pure the product is, how much to use, or when to stop.

We do know that creatine produces no improvement in long-term endurance activities. A number of side effects are possible, including abdominal pain, nausea, loose stools, increase in weight due to the retention of water, muscle cramps, and muscle strains. Case reports indicate that dehydration and even death may occur when athletes take creatine and exercise in hot weather. Reduction in kidney function and enlargement of the heart muscle have been observed in kids. Additionally, creatine supplementation suppresses the body’s own production of creatine. We do not know what effects this may have on a growing child. There are simply too many unknowns about creatine at this time. It would be wise to stop the current hype.



Anabolic Steroids
Anabolic steroids are synthetic testosterone derivatives. They have become very popular with athletes who seek improved muscle size and strength, whether to gain an advantage in competition or simply to look better in a culture that reveres large, muscular bodies. Athletes at high abuse risk for these products include those involved with football, weight lifting, wrestling, shot putting, discus throwing, sprinting, and many other sports.

A number of anabolic steroid products have been available over the past several decades, including stanozolol (Winstrol7), nandrolone decanoate (Deca-Duraboline7), oxymetholone (Anadrol-507), and others. One form, methandrostenolone (Dianabol7), was available in the 1970s and 1980s as an injection and was abused by many teens. After various needle-related consequences were reported (e.g., hepatitis, HIV infection), methandrostenolone was discontinued. Today, however, a pill form is making a comeback.

Anabolic steroids are very popular around the world. Up to 11% of American high school males and up to 2.5% of high school females use anabolic steroids—a staggering number! We know that half of these abusers start with steroids while under the age of 16. About one-third of steroid users do not consider themselves athletes. We also know that the desire to excel in sports and/or personal appearance drives young people to use high doses of anabolic steroids, often in combination with other drugs. Can these kids gain muscle mass and strength? Yes, but only if they also engage in specific, strenuous exercise training at the same time. Using steroids without this training does not increase weight and power.

Anabolic steroids: a time bomb
Kids who use anabolic steroids are fooling around with a time bomb. Many dangerous side effects await the unwary user of these dangerous chemicals. Females can become masculinized, with excessive hair growth (called hirsutism), enlargement of the clitoris, and loss of hair (seen in males also). Growing athletes may increase the maturing of growth plates in bones, resulting in a shorter height than they would otherwise attain. Acne may become very severe and resistant to therapies. Some steroid users become aggressive and irritable; some become depressed. Testosterone levels may drop with reduction in the size of testicles. There are many other potential problems, such as stomach ulcers, increased blood sugar, fluid retention, and increase in injuries to tendons. Some scientific articles report a link between liver cancer and the use of anabolic steroids.

Athletes may take additional drugs in an attempt to augment the effects of anabolic steroids and/or reduce some of the side effects. Many athletes become involved with a dangerous practice known as stacking, taking many drugs at high doses for weeks or months. Some stop only before a sports event, and only if they will be tested for drugs. Some female athletes try to take just enough to become more powerful but not enough to become masculinized. Officials at the Olympic games have banned anabolic steroids from competition and have been testing for them since the 1970s.

Looking for safe alternatives
The athletic world constantly seeks safe alternatives to anabolic steroids. For example, athletes have tried a chemical called, androstenedione. It is related to testosterone and is taken an hour or so before a sports event to improve power and strength. Well-known professional athletes have even used it. However, it is not really effective and it has become less popular today.

DHEA beware
DHEA (dehydroepiandrosterone) is another chemical that is related to testosterone (and also estrogen) and promoted in nutrition stores. It is widely advertised as a wonder drug that will improve muscle size and strength, lessen depression, prevent heart disease, and increase sex drive among other unproven claims. A reputed fountain of youth, it has special appeal to adult athletes. Though hyped as a safe alternative to anabolic steroids, it is not safe and is linked to many anabolic steroid-like side effects. Excessive hair growth and endometrial cancer are reported in women, while prostate cancer and permanent breast development are reported in men. Yes, this natural product is found in human adrenal glands and even in wild yams. It is, however, a dangerous chemical. Young people and adults alike should be discouraged from using it.



Protein and Amino Acid Supplements
The use of protein and amino acid supplements to improve sports performance has been promoted for the past several decades. Do athletic children need more protein than their non-exercising peers? Yes. Does protein supplementation help their sports activity? No. Most athletes get more than enough protein from their normal intake of food. There are some athletes who try to stay very thin and/or lose weight, such as gymnasts, dancers, and wrestlers. Providing extra protein may help this select group. I do not recommend expensive protein supplements for them. I suggest they get their additional protein from evaporated milk or relatively inexpensive protein powder (egg or soy).

The use of branched-chain amino acids to increase growth hormone production has not been proven to help the athlete perform better. I point out to athletes that protein or amino acid supplements can be ineffective and needlessly expensive. Overuse may even lead to loose stools. I worry that an overabundance of some amino acids may lead to an imbalance of others and that unknown side effects may result from such supplementation.






Common Questions
Here are some questions I often receive from parents and teens regarding sports doping:

What about the use of Antioxidants?
Antioxidants are chemicals that are thought to reduce the amount of body damage done by free radicals. Some athletes are concerned that harm may be caused by the production of exercise-induced free radicals. Some antioxidants include vitamin C (ascorbic acid), vitamin E (alpha tocopherol), beta carotene (a vitamin A precursor), iron, zinc, selenium, manganese, and copper. At this point, we do not really know if these antioxidants improve sports performance. More research is needed in this area. Everyone should get a recommended amount of these substances in their diets. For example, the recommended daily allowance is 10 mg a day for vitamin E and 60 mg a day for vitamin C. Extra doses of some chemicals (such as vitamin C or beta carotene) may cause illness.

Is there a role for iron supplementation?
It has not been shown that iron will improve sports performance or that most athletes need or would benefit from iron supplementation. Runners and other endurance athletes do lose iron in their intestinal tracts, urine, and sweat, and may need more dietary iron than non-athletes. Normally, they will consume what iron they need in their diet. Athletes with a low iron level will benefit from taking a daily multivitamin with iron. This includes vegetarian teens as well as females with excessive menstrual blood loss and limited dietary iron.

Is calcium necessary?
Calcium itself is not ergogenic, i.e., does not produce sports performance improvement. It is recommended, however, that individuals between 11 and 24 years of age receive a daily intake of 1200 to 1500 mg of calcium. If intake of calcium is below this level, then supplementation is warranted. Female athletes who are required to be thin, such as gymnasts or dancers, may be on a low calorie diet and have low estrogen levels. They are at increased risk for fractures, absence of menstrual periods, and, later in life, osteoporosis. They are often afraid of calcium-rich dairy products, which may contain too much fat for them. I suggest they take yogurt or skim milk in this case.

Are there other amino acids and chemicals taken as muscle drugs?
Yes. A popular muscle drug is HMB (beta-hydroxy beta-methylbutyrate), a leucine metabolite found in citrus fruits, breast milk, and even cat food. Some studies show it increases muscle size and may allow the muscle to repair itself faster. Its effectiveness as a sports doping agent and its potential long-term side effects are unknown at this time.

Other unproven amino acids on the market include L-carnitine (found in dairy products and meats), Arginine, Glutamine (found in almonds, soybeans and peanuts), and Conjugated Linoleic Acid or CLA (found in yogurt, milk, treated cheese, venison, and beef). We do not know enough about these agents. Their use should be discouraged. The exact dose found in each bottle is unclear. They may contain impurities as well. In the 1980s, another amino acid, L-tryptophan, was linked to deaths due to impurities. Side effects observed include diarrhea with L-carnitine and drowsiness with L-tryptophan. We also do not know the effects of adding these chemicals to other sports doping agents. I advise athletes to play it safe and avoid these drugs.

A published study suggests that chromium (an essential trace element) can lead to muscle gain and a reduction in body fat. Other studies, however, have not confirmed chromium’s ergogenic properties. Side effects include gastrointestinal upset, anemia, and kidney disease. I only recommend chromium as part of a multivitamin tablet, one that does not exceed 200 mg/day of this element.

Another trace mineral, vanadium, has been marketed as a muscle builder. I tell my patients that there is no proof of this and that side effects may include diarrhea, abdominal cramps, and even a green tongue.

What about Boron?
Boron is a substance essential for plants but not humans. It is present in foods of plant origin, non-citrus fruits, leafy vegetables, nuts, and legumes. Although boron is sold to increase muscle mass, there are no studies to support claims of increased lean body mass, total testosterone, or strength.

Do some athletes give themselves their own blood to improve sports performance?
Yes. This is called blood doping (also blood packing or blood boosting). The individual saves his or her own blood and takes it intravenously before a sports event. This increases hemoglobin (protein in the blood which carries oxygen) to a high level and may allow increased endurance. Laboratory tests are not able to catch athletes who use this method. Some athletes take a product called erythropoetin, or EPO, which also increases oxygen-carrying capacity. In both cases, the blood becomes thicker, increasing the risk of strokes, heart attacks, and seizures. I tell my patients that blood doping is not allowed by sports authorities. The risks are not worth any benefit it might produce.

I have asthma. Can I take my medications? I have heard that asthma medications are not allowed for sports participation.
It is perfectly fine and indeed important for athletes with asthma to take asthma medications. These medicines include terbutaline, albuterol, and others. The confusion developed because of a medication called ephedrine. This is a stimulant drug that can also help asthma. Stimulant drugs (like ephedrine, amphetamine, and caffeine) give the athlete an unfair advantage and are not allowed in Olympic and other competition. They have a number of side effects, including increased aggressiveness, higher blood pressure, increased heart rate, loss of fluids, shakiness, and anxiety. Some athletes find that too much coffee may lead to increased urination and too many trips to the bathroom. Olympic officials have limited the amount of caffeine they will allow their athletes to take.

Are pain pills okay?
In general, it is fine to take pain pills to relieve pain from sports-related injuries. It is important to take them under a knowledgeable clinician’s direction. Some athletes have taken too many of these pills in the face of injury so they can continue with the game. This may lead to even more severe injury. I tell parents to be sure to seek careful evaluation and treatment for children who are hurt in sports. Don’t come back to the game too soon. Come back when you are healed and ready.

Why are diuretics banned in sports?
Diuretics are medications that increase urine output. They are used inappropriately by athletes who need to lose weight in a hurry (wrestlers, for example). These medicines are also used to mask the presence of other performance enhancing drugs. Athletes should be advised that using diuretics for such purposes is wrong and that a number of side effects may result, including dehydration, weakness, and heart irregularities. In addition, weakness caused by diuretic use can make an athlete more susceptible to injury.

Is it okay to use medications to calm the athlete’s nerves?
An athlete who is diagnosed with an anxiety disorder may benefit from certain medications known to improve anxiety. These are fine to take. Some athletes take pills called, beta-blockers (such as propranolol). These are used to reduce performance anxiety by controlling hand tremor, lowering heart rate, and reducing blood pressure. They are banned in some Olympic sports.



Summary
The best sports performance method is to combine a vigorous exercise plan (under the supervision of a qualified person) with a well-balanced diet. The use of chemicals and drugs is fraught with many unnecessary dangers, as outlined in this article. Parents should be guardians of their children and be sensitive to the societal pressures on their children to win at all costs. These drugs do not usually work and are not worth the price our children may pay. I advise you to tell your children, coaches, and schools to discourage the practice of sports doping. The safety of your children is at stake.