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HEALTHNOTES Tummy tuck, mini tuck

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HEALTHNOTES Tummy tuck, mini tuck

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									                                                                    Fall 2007 Volume 26 Issue 3



                                 HEALTHNOTES
  A P u b l i c At i o n o f t h e h e A lt h e d u c At i o n d e PA rt m e n t


Looks To Die For: Dr. 911                                 ON THE BACK
by Philip A. Belcastro, Ph.D.
    In a typical “reality” television episode featuring
                                                          Prescribing Medicines
Elective Cosmetic Surgery (ECS) a young woman,            Based On Skin Color
dissatisfied with small size breasts, is filmed select-
ing her new breast size with her surgeon. The epi-
sode concludes with the delighted patient unveiling
her newly installed breasts to girlfriends at a pool
party. “Reality” television programs are immensely
popular and have a significant pseudo-educational
impact on Americans. Viewers who regularly watch
ECS “reality” shows: (1) are more likely to undergo
ECS; (2) believe these television shows accurately
portray the totality of ECS practices; and (3) believe
they are knowledgeable about ECS (Crockett et al.,
2007; McGrath & Schooler, 2004). The danger here
is that these viewers may fall victim to the known
risks of ECS for example: there is a higher-than-
expected suicide rate among women with breast
implants; physicians perform cosmetic procedures
with as little training as a weekend seminar or after
watching a thirty-minute video; and the mortality
Continued on page 2

Are Circumcised Males Less
Likely To Contract HIV?                                   HEALTHNOTES is edited by
                                                          Professor Philip A. Belcastro, Ph.D.,
by Danna Ethan, MA, MSW                                   Chair of the
    Significant research findings from three clinical     Health Education Department
trials reported that male circumcision (removal of        Borough of Manhattan
the foreskin covering the glans, or tip of the penis)     Community College/CUNY
                                                          199 Chambers Street
significantly reduces the risk of HIV transmission
                                                          New York City, New York 10007
in African men. The studies carried out in Uganda,
South Africa and Kenya randomly assigned men to           212-220-1453
either the intervention group (receiving circumci-        Contributing Editors
sion) or to the control group (receiving a delayed        Danna Ethan
circumcision) (Auvert et al., 2005; Bailey et al.,        Gloria McNamara
2007; Gray et al., 2007). All three clinical trials       Kindly contact the Health Education
were halted early when it was clear that the              Department for comments or to
Continued on page 6                                       add your name to the recipient list.
Looks To Die For:                          implants are more likely to: have had
Dr. 911                                    a higher number of lifetime sexual
                                           partners; use birth-control hormones;
Continued from page 1
                                           be younger at their first pregnancy;
                                           have a history of abortions; frequently
(death) rate for lipoplasty (e.g. “tum-    consume alcohol and tobacco; have a
my-tucks”) in America is higher than       higher divorce rate; and be below aver-
the mortality rate for motor vehicle ac-   age body weight (suggesting the pres-
cidents or homicides. Given the risks      ence of an eating disorder) (Sarwer
associated with the more than 11 mil-      et al., 2007). Noting these criticisms
lion cosmetic procedures preformed         one of the most comprehensive re-
in America each year…one should            search reviews to date, examining six
not rely on Dr. 90210 for a second         major studies since 1992 concluded
opinion.                                   that the suicide rate of women receiv-
                                           ing breast implants was indeed twice
Breast Augmentation & Suicide              that expected in the general popula-
   For some time there has been            tion (Sarwer et al., 2007).
concern of a correlation, that is a            Another aspect of breast aug-
link between suicide and ECS breast        mentation is breast reduction. While
implants. McLaughlin et al. (2004)         research does not point to a risk of
report that there is a 200% to 300%        suicide associated with breast reduc-
increase in suicide for women with         tion, there is some evidence that
cosmetic breast implants when com-         breast reduction does not result in an
pared to women in the general popula-      enduring improvement of the woman’s
tion. Lipworth et al. (2007) followed      quality of life, mental health, self-
3527 Swedish women ten years after         esteem or body image (Cook et al.,
their cosmetic breast implant surgery.     2006).
These researchers concluded that               ECS patients are often repeat cus-
there was an excess of deaths from         tomers, sometimes not by choice. It is
suicides, drug and alcohol abuse/          not uncommon for the first breast aug-
dependence and other related causes.       mentation to be followed by a second
Rohrich et al. (2007) argue that           or multiple surgeries resulting from
studies finding a correlation between      the patient’s dissatisfaction; failure
suicide and breast implants are often      of the implant; maturation (pre-teens
flawed because their samples (num-         and teens maturing into their adult
ber of women they studied) were too        bodies); aging; pregnancy; or change
small to accurately reflect the actual     of mind for a different cosmetic look.
suicide rate from breast implants.             All of these investigators, regard-
These researchers further argue that       less of their point of view as to the
the demographics and lifestyle of          link of breast implants to suicide,
women seeking breast implants lend         recommend pre-surgery screening of
themselves to a higher risk of sui-        patients for psychiatric illness, as well
cide. Indeed women seeking breast          as long-term post surgery monitoring

2    HEALTHNOTES     FALL 2007
of cosmetic breast surgery patients.         1 in 13,000. These researchers warn
All of these investigators recommend         that “…the morbidity and mortality
further study to determine which pro-        rates from abdominoplasty remain
spective breast augmentation patients        unacceptably high.”
are at greater risk of psychiatric illness
or self-harm.                                Injectable Soft Tissue Fillers
                                                 Injectable soft tissue fillers are
Body Dysmorphic Disorder                     used to mask wrinkles, swell lips or
    Another related concern in ECS           raise cheek-bones. Soft tissue fillers
practices is the relatively frequent         are categorized as “devices” and not
occurrence of the patient with Body          drugs by the FDA. Numerous products
Dysmorphic Disorder (Jakubietz et al.,       are on the market and many evolve
2007). Body Dysmorphic Disorder is a         from one brand-name to another.
psychiatric disease characterized by a       Nearly all are temporary solutions last-
person’s preoccupation with a mini-          ing as short as a few months for up to
mal or nonexistent appearance defect         six months. Sculptra® and Radiesse®
which causes significant distress and        which are “semi-permanent” fill-
interferes with the person’s social life.    ers may last up to two years. These
The perceived physical defect may            products require multiple treatments
involve the profile of the whole body        costing, in some cases, thousands of
or may be focused on a part of the           dollars. According to the American
body such as the breasts. Crerand et         Society of Plastic Surgeons (2007)
al. (2006) report that seven to fifteen      ArteFill® is a “permanent” soft tissue
percent of ECS patients may suffer           filler, yet may still require multiple
from Body Dysmorphic Disorder.               applications.
                                                 Injectable soft tissue fillers may
Lipoplasty                                   dissipate unevenly, causing disfigure-
    Lipoplasty is a major surgical pro-      ment. All soft tissue fillers can result
cedure to remove excess skin and fat         in adverse effects, with the non-
from various parts of the body includ-       biodegradable products more likely to
ing the abdomen (abdominoplasty),            cause severe, persistent and recurrent
buttocks, thighs and upper arms. The         complications (Andre, 2005). Such
surgical death rate of lipoplasty in         adverse effects include: lumping;
America is higher than the death rate        clumping; swelling; redness; granulo-
for motor vehicle accidents or homi-         mas; bruising; allergic reactions; itch-
cides (Lapetina & Armstrong, 200).           ing; rash; pain; discoloration; numb-
Several researchers including Lapetina       ness; and droopy eyelids.
& Armstrong (2002) comment that                  The “off-Label” administration of
the death rate of lipoplasty in America      prescription drugs permits physicians
may be in fact much higher than re-          to administer a drug to a patient for
ported. Yoho et al. (2005) report that       conditions not approved for use by the
the mortality rate just from the general     FDA. This is also true for devices such
anesthesia administered during ECS is        as injectable soft tissue fillers. So a

                                                      HEALTHNOTES      FALL 2007    3
physician may inject a soft tissue filler   The Reality Totality
in an area of the body or for a specific        The majority of ECS procedures
application that is not approved for        are preformed safely and to the rea-
use by the FDA. One essential inter-        sonable satisfaction of the patient.
view question of the elective cosmetic      However, there are men and women
surgeon, indeed any prospective phy-        each year that undergo breast aug-
sician, is whether he intends to use        mentation, “tummy-tucks”, rhino-
off-label drugs or medical devices in       plasty (nose-job) and scores of various
your surgical or non-surgical proce-        cosmetic repairs and enhancements
dure.                                       which result in the necessity of ad-
                                            ditional surgery; permanent neuro-
Inpatient vs. Outpatient Surgery            logic injury; or death. Because ECS
    A major risk of all surgeries is the    is “elective” the risks of surgery carry
administration of general anesthesia        greater weight than surgery that is ne-
and sedation. The setting in which          cessitated to cure illness, disorders or
general anesthesia and sedation is          save a life. This is not said to discount
administered is correlated to the risk      the benefit of ECS resulting in the
of death or permanent neurologic in-        improvement of a person’s emotional
jury. Hospital settings are considerably    health and social functioning. The key
safer than non-hospital (outpatient)        task for the prospective ECS patient
settings especially for ECS. Lapetina       is to select a physician and in turn a
& Armstrong (2002) report that when         surgical facility that will provide the
a patient had an adverse reaction to        maximum potential in performing the
general anesthesia or sedation in a         necessary screening, consultation,
hospital setting approximately 37%          surgical expertise, risk management,
suffered permanent neurologic injury        and post-operative care associated
or died. In stark contrast when a           with the ECS procedure. A second
patient had an adverse reaction to          step is to explore with your physician
general anesthesia or sedation in a         non-surgical remedies for your physi-
non-hospital setting approximately          cal defect such as the use of cosmet-
93% suffered permanent neurologic           ics or dress. The one step you should
injury or died. A primary reason for        not take is download a video clip of
this disparity is that the physician        Dr. 90210 onto your I-Pod, cart it to
operating in a non-hospital setting         the nearest ECS clinic and promptly
is often a solo practitioner without        schedule surgery to “…look just like
immediate access to the equipment,          her.”
facilities and specialized physicians
needed to respond to a medical emer-        Professor Philip A. Belcastro is Chair
gency resulting from general anesthe-       of the Health Education Department
sia or sedation. Indeed the protocol        at BMCC~CUNY.
for such surgical medical emergencies
in a non-hospital setting is for the
cosmetic surgeon to dial 911.

4    HEALTHNOTES      FALL 2007
References                                Lipworth, L., Nyren, M., Ye, W. et
American Society of Plastic Surgeons.       al. (2007) Excess mortality from
 (2007). Injectables at-a-glance.           suicide and other external causes of
 Posted at: http://www.plasticsurgery.      death among women with cosmetic
 org/media/press_releases/Inject-           breast implants. Annals of Plastic
 ables-at-a-Glance.cfm                      Surgery. 59(2):119-123.
Andre, P, Lowe, N., Parc, A. et al.       McGrath M. & Schooler W. (2004).
  (2005). Adverse reactions to dermal      Elective plastic surgical procedures
  fillers: a review of European experi-    in adolescence. Adolescent Medi-
  ences. Journal of Cosmetic & Laser       cine Clinics. 15(3):487-502
  Therapy, 3-4:171-6.                     McLaughlin J., Wise T. & Lipworth L.
Cook SA, Rosser R, Salmon P. (2006).       (2004). Increased risk of suicide
  Is cosmetic surgery an effective         among patients with breast im-
  psychotherapeutic intervention? A        plants: Do the epidemiologic data
  systematic review of the evidence.       support psychiatric consultation?
  Journal of Plastic Reconstructive &      Psychosomatics. 45(4):277-80.
  Aesthetic Surgery, 59(11):1133-51.      Sarwer, D., Brown, G. & Evans, D.
Crerand CE., Franklin ME., & Sarwer         (2007). Cosmetic breast augmen-
  DB. (2006) Body dysmorphic dis-           tation and suicide. The American
  order and cosmetic surgery. Journal       Journal of Psychiatry. 164(7):
  of Plastic & Reconstructive Surgery,      1006-13.
  118(7):167e-80e                         Yoho R., Romaine J. & O’Neil D.
Crockett, R., Pruzinsky, T. & Pers-         (2005). Review of the liposuc-
  ing, J. (2007). The influence of          tion, abdominoplasty, and face-lift
  plastic surgery “reality TV” on           mortality and morbidity risk litera-
  cosmetic surgery patient expecta-         ture. Dermatologic Surgery. 31(7 Pt
  tions and decision making. Journal        1):733-43.
  of Plastic & Reconstructive Surgery,
  120(1):316-24.
Jakubietz, M., Jakubietz, R., Kloss,
  D. et al. (2007) Body dysmorphic
  disorder: diagnosis and approach.
  Journal of Plastic & Reconstructive
  Surgery, 119(6):1924-30.
Lapetina, E. & Armstrong, E. (2002).
  Preventing errors in the outpatient
  setting: A tale of three states.
  Health Affairs, 21(4): 26-39.




                                                  HEALTHNOTES      FALL 2007      5
Are Circumcised                           They are concerned that some newly
Males Less Likely To                      circumcised men may stop wearing
                                          condoms or increase their number of
Contract HIV?                             sex partners in light of these encour-
                                          aging findings. Also, men who have
Continued from page 1
                                          sex before their circumcision wound
benefits of circumcising the men far
                                          heals could increase their chances of
outweighed non-circumcision with
                                          infection.
regard to lowered rates of HIV infec-
tion. Men who were circumcised had
                                          Male Circumcision in the U.S.
a 55% (Uganda), 60% (Kenya) and
                                              In the United States, 60-70%
76% (South Africa) risk reduction of
                                          of infant boys are circumcised. The
HIV infection as compared with men
                                          procedure usually is preformed after
who were not circumcised.
                                          birth. Factors influencing the decision
    There may be reasons other than
                                          to circumcise male newborns include
male circumcision for the reduced risk
                                          religion, culture, parents’ preference,
of HIV infection in these particular
                                          and health reasons. Parents who
studies. For example in the Kenyan
                                          choose not to circumcise their son do
study men’s tribal affiliation was sig-
                                          so because of similar reasons, as well
nificantly correlated with HIV status,
                                          as the belief that there is no compel-
regardless of circumcision. (Shaffer et
                                          ling medical benefit to male circumci-
al., 2007). Among men in tribes with
                                          sion.
higher rates of HIV, the rate of sex
                                              The American Academy of Pedi-
reported with a commercial sex worker
                                          atrics (AAP) does not recommend
was significantly higher. In turn, men
                                          circumcision as a routine procedure,
in tribes that were more monoga-
                                          since it does not significantly promote
mous had lower rates of HIV infection
                                          a boy’s well-being at birth. Rather,
regardless of circumcision. Also, in
                                          the AAP recommends that parents
comparison with uncircumcised men,
                                          consult with their son’s physician to
the men who were circumcised were
                                          gain a better understanding of the
more likely to have had the procedure
                                          possible risks and benefits associated
performed by a traditional practitio-
                                          with circumcision in order to make an
ner (physician) versus a health care
                                          informed decision.
worker. In light of these findings,
                                              Adult men also choose to become
the influence of tribal affiliation and
                                          circumcised. Most men who undergo
sexual practices on men’s HIV status
                                          this procedure do so because of medi-
should be examined further before
                                          cal reasons. (Fink, Carson & DeVellis,
sweeping policy changes are made
                                          2002). The most common medical
with regard to circumcision.
                                          reason is phimosis, a tightness of the
    Critics of these recent studies
                                          foreskin that prevents it from retract-
warn that male circumcision is not a
                                          ing over the glans. As with any type of
“miracle solution” for HIV transmis-
                                          medical procedure, there are related
sion. (Butler & Odling-Smee, 2007).
                                          risks. The most common complica-

6   HEALTHNOTES      FALL 2007
tions of the procedure are minor infec-   References
tion and bleeding. Full recovery after    Auvert B, Taljaard D, Lagarde E,
circumcision typically requires four to     Sobngwi-Tambekou J, Sitta R, &
six weeks of abstinence from mastur-        Puren, A. (2005). Randomized,
bation and sexual activity.                 controlled intervention trial of male
Applicability of African Studies            circumcision for reduction of HIV
to the U.S.                                 infection risk: The ANRS 1265 trial.
    HIV transmission in Africa oc-          Public Library of Science Medicine,
curs primarily through penile-vaginal       11:e298.
intercourse. The major modes of HIV       Bailey RC, Moses S, Parker CB, et al.
transmission in America are with MSM       (2007). Male circumcision for HIV
(men who have sexual behaviors with        prevention in young men in Kisumu,
men) and drug IV (needle) use. This is     Kenya: a randomized controlled trial.
not to discount the significant propor-    Lancet, 369:643-656.
tion of heterosexuals contracting HIV
via penile-vaginal intercourse. Also,     Butler, D. & Odling-Smee, L. Cir-
the overall HIV risk in the United         cumcision for HIV needs follow-up.
States is much lower than in Africa;       (2007). Nature, 447:1040-1041.
and more American men are circum-         Fink KS, Carson CC, DeVellis RF.
cised than in Africa. The findings from     (2002). Adult circumcision out-
the African studies have nonetheless        comes study: effect on erectile
peaked the interest of the American         function, penile sensitivity, sexual
public health community. The Centers        activity and satisfaction. Journal of
for Disease Control has recommended         Urology, 167, 5:2113-2116.
that additional research be conducted
                                          Gray RH, Kigozi G, Serwadda D, et
to evaluate the potential value, risks
                                            al. (2007). Male circumcision for
and feasibility of circumcision as a
                                            HIV prevention in men in Rakai,
strategy to reduce HIV transmission in
                                            Uganda: a randomized trial. Lancet,
the U.S. As promising as these results
                                            369:657-667.
are, it is important to remember that
abstinence, reducing the number of        Shaffer D, Bautista C, Sateren W,
sex partners and correct and consis-        Sawe F, Kiplangat S, Miruka A, Ren-
tent condom use are the most effec-         zullo P, Scott P, Robb M, Michael N,
tive forms of protection against HIV        Birx D. (2007). The protective effect
transmission. Indeed, rubber latex          of circumcision on HIV incidence
condoms should be applied in all            in rural low-risk men circumcised
sexual behaviors involving the penis of     predominantly by traditional circum-
both circumcised and uncircumcised          cisers in Kenya: two-year follow-up
males.                                      of the Kericho HIV cohort study.
                                            Journal of Acquired Immune Defi-
Professor Danna Ethan is a faculty          ciency Syndrome, 45,4:371-379.
member of the Health Education
Department.

                                                   HEALTHNOTES      FALL 2007       7
Prescribing Medicines Based On Skin Color
by Rachel Torres, Ed.D.                    Sachs or cystic fibrosis affect dis-
    The FDA recently approved the          tinct ethnic/racial groups. However,
first race-based drug, BiDil, to treat     heart disease is not presently linked
heart failure specifically in African      to a specific gene trait. The cur-
Americans (Brody & Hunt, 2006).            rent wisdom is that heart disease is
Initially, the FDA had rejected the ap-    influenced by many factors outside of
proval of this drug because it seemed      genetic traits such as: socioeconomic
to be ineffective in clinical trials       status, environment and education.
involving the general population.          The danger here is that prescribing a
However, these same clinical trials        drug that targets a disease in a spe-
demonstrated a favorable response          cific ethnic/racial group may discount
by African Americans prompting the         the influence that other factors may
company to investigate the effective-      have in the onset and progression of
ness of the drug in persons of color.      the disease.
BiDil demonstrated effectiveness in            While there are issues about the
persons of color and subsequently          feasibility of race-based drugs, it is
was approved for use by the FDA.           important to acknowledge that this
BiDil’s approval raises some interest-     latest drug approval is moving medi-
ing and controversial issues.              cine in a direction towards individual-
    The idea behind BiDil is that          ized or personalized medicine. We do
higher mortality rates from heart          have drugs that are targeted based
failure are in part a result of biologi-   on age and sex, so it may also make
cal or genetic differences among the       sense to look at drugs that target
races. It may be that different racial     genetic differences. It remains to be
groups harbor different reasons for        seen how effective BiDil as a race
getting heart disease and/or different     prescribed medicine, will be in treat-
racial groups respond differently to       ing heart disease.
heart disease medications (Risch et
al. 2002). However, looking at race        Dr. Rachel Torres is an adjunct
alone may be an overly simplistic          professor in the Health Education
view of how genetic make-up affects        Department at BMCC/CUNY.
disease. One confounding issue is
that persons of color represent a          References
genetically diverse group of people.       Risch, N., Burchard, E., Ziv, E &
Their origins may be from different          Tang H. (2002). Categorization of
parts of the world such as Africa, the
                                             humans in biomedical research:
Caribbean and the United States.
This genetic diversity may present a         genes, race and disease. Genome
problem when prescribing medica-             Biology, 1:3(7): Epub, 2002 Jul 1.
tions based solely on the color of a       Brody, H. & Hunt L. (2006). BiDil:
person’s skin.                               Assessing a Race-Based Pharma-
    There are indeed genetic diseases        ceutical. Annals of Family Medi-
that can be found in large ethnic and        cine, 4(6): 482-483.
racial groups. Diseases such as Tay-


8    HEALTHNOTES      FALL 2007

								
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