Elective plastic surgery done for cosmetic gain always take a careful look at the patient’s general health beforehand. With some notable exceptions (morbid obesity, diabetes, smokers) it is fair to say that any person under the age 50 is unlikely to have medical problems that would exclude them from having almost any type of plastic surgery safely. Most certainly, the most athletic and fit individuals would seem to be ideal candidates to undergo a surgical experience without incident. Recent reports have pointed out, however, that there is one unique athletic patient that is at risk of the heart stopping (asystole) during surgery. Several cases have now emerged in young women who were endurance trained (marathon runners) with presurgical slow heart rates below 60 (bradycardia) that are at risk for cardiac arrest during surgery. The exact mechanism is not fully understood why this can potentially happen. Ironically the most very fit, perhaps unnaturally fit, patient has an increased cardiac risk for surgery in general if they have a low heart rate. While no deaths have been reported from these events happening in surgery, plastic surgeon and anesthesiologist need to be on guard in the athletic patient with a slow heart rate.

As tax day is upon us, many are pondering what deductions of expenses they can and should take. In that spirit I occasionally will get asked by a patient whether the costs from their plastic surgery are tax-deductible. Most are joking of course but a few I think are serious. As I am a plastic surgeon and have no knowledge about tax law, I recommend they ask a tax expert, lawyer or accountant, about their filing questions.

It would be hard to imagine that any type of cosmetic surgery would ever be deductible, but apparently there have been a handful of patients that have been able to take their procedures as a legitimate expense. In an article that appeared today in the journal Plastic Surgery Practice written by a tax expert, several successful tax cases were reviewed. One case was an exotic dancer whose breast implants were so large that were considered a legitimate expense to benefit her career. The other was a case of transgender surgery as the underlying condition was deemed medical in origin due to the diagnosis.

According to the article and the tax experts, cosmetic surgery may be considered a deduction if it satisfies two criteria. It must be a condition of employment and that the procedures do not create benefits for everyday use. In addition while partial deductions can be taken for expenses paid for medical care, cosmetic surgery is specifically excluded unless it is considered corrective. (I assume this falls into the classic distinction between what we as plastic surgeons call reconstructive vs. cosmetic) This would appear to mean those phsyical deformities that emanate from either congenital, traumatic or disease origins. They cite the most notable example of the difference between placing implants and other procedures for elective breast augmentation (cosmetic) vs that of re-creating a lost breast from cancer. (reconstruction) Another example would be the difference between a typical tummy tuck vs that of an abdominal panniculectomy due to the differences in medical symptoms that the pannus causes.

As a plastic surgeon, it appears that the tax distinction between pure cosmetic surgery and that of reconstructive surgery is very similar as to how medical insurance determines coverage of specific plastic surgery procedures. But the best answer for that comes from the patient’s tax advisor.

Dr. Barry Eppley

Indianapolis, Indiana

While over 14 million plastic surgery procedures were performed in 2012, the types of procedures differed considerably across the various age groups. The age group of 35 to 50 year-olds makes up the highest percentage (43%) with efforts being made to slow down the effects of aging which are now unavoidable to overlook. This is why this age group accounts for almost 50% of Botox and injectable filler use. Concomitantly, the use of laser, chemical peels and light therapies are also prevalent in an effort for skin improvement and wrinkle reduction. Reversing the effects of childbearing are seen in the high number of  breast augmentations, tummy tucks and liposuction in this age group as well. The age group 51 to 64 year olds are the next highest users at 28% of the cosmetic pie. As 60 is the new 50, facial surgical procedures dominate with nearly two-thirds of all eyelid lifts, browlifts and facelifts occurring in this group. The 19 to 34 year-old age group accounted for 20% of procedures done with breast augmentation, liposuction and rhinoplasty being common surgeries and laser hair removal and microdermabrasion being the most commonly done non-surgical procedures. At the opposite ends of the age groups, the 65 and older group (9%) and under the age of 19 (1%) made up the rmaining 10% of the procedures performed.

The United States leads the world in many categories so it is no surprise that the greatest number of cosmetic surgeries are performed here as well. (recent estimates have it as over 20% of the world’s total) With the number of board-certified plastic surgeons exceeding 6,000, the number of procedures performed by them follow as well. By comparison, neighboring Canada has less than 10% of the number of plastic surgeons as well as the original home country of the UK. Only Brazil on the lower adjoining continent boasts similar numbers of plastic surgeons and large number of cosmetic procedures as well. But when adjusted for number of procedures per population, the U.S. is not number one…South Korea is. Even Italy and Greece have higher numbers when adjusted for percent of their population partaking in cosmetic surgery procedures.

Aging may have more negative effects than just on one’s appearance. A recent study from the American Heart Association indicates that it may be a sign of heart disease as well. This is not heart disease that could occur in anyone if they simply live long enough but an indicator of a predisposition to heart problems.

The study reports that those patients who had a number of visible signs of aging had increased rates of heart attacks and of developing heart disease. The markers of aging included hair loss with recession at the temples and baldness at the crown, skin creases in the earlobes and fatty deposits around the eyelids known as xanthelasmas. It is no surprise to me that xanthalasmas suggest an increased risk of heart disease given that they represent cholesterol deposits from elevated levels of lipids in the blood. They were also the strongest predictors of heart disease risk. Hair loss and earlobe creases are bit harder to make an obvious connection to heart disease.

What is impressive about this report and study is the large number of patients followed for a long period of time. In this Danish study, over 11,000 patients  age 40 years or older were studied for over 35 years beginning in 1976. These aging signs predicted heart attacks and disease independent of traditional risk factors such as elevated cholesterol levels, high blood pressure and smoking. Also the common aging signs of gray hair and skin wrinkles were ruled out as predictors of heart disease and are reflective of chronological aging but not a risky heart condition.

This study is of medical importance in that internists and family practitioners should look for these physical signs and consider lifestyle changes and lipid lower therapies for those patients who have them.  But these aging signs can also be treated directly through various common plastic surgery procedures. Hair transplantation is a well known treatment for temporal recession and loss of hair at the crown. Usually earlobe creases represent an excess of earlobe tissue and larger earlobes. These creases can be removed through a simple earlobe reduction done through a wedge resection technique. Xanthalasmas are a common condition that plastic surgeons see and are challenging in terms of removal. Usually appearing on the lower eyelids and cheek, they are often dozens of small yellow white plaques located just under the skin. Numerous techniques have been described but I find micro-excision (making a small slit and pushing out the plaque) to be most successful for larger ones.

While the numerous physical signs of aging can be improved or reduced by plastic surgery, this unfortunately does not reduce the risk of heart attacks and disease as well. Their outward appearance can be modified but the underlying genetic code can not be so favorably manipulated.

Dr. Barry Eppley

Indianapolis, Indiana

Last week Phyllis Diller died at the age of 95. She was known for many things, from her eccentric dress, wild hair and outrageous laugh, but her stage persona was one that few would forget even by today’s comedic standards. Besides her well known comedy stand-up skills, she was also an accomplished pianist and painter which is less well known. But besides comedy, she is equally known for her forthrightness about having plastic surgery even at a time when having such procedures was far less pervasive in society and accepted as it is today.

While she joked frequently about the plastic surgery she had undergone, she had much to joke about. She reportedly had her first procedure at age 55 in 1972. Over the next two decades, she is known to have had by her own admission over fifteen procedures by almost ten plastic surgeons. She is known to have had facelifts, breast reduction, rhinoplasty, browlift, cheek implants blepharoplasties, and chemical peels Her extensive plastic surgery resume was even a subject of a 20/20 segment back in 1993. Wikipedia dedicated a section of her plastic surgery in its listings of her life and accomplishments.

While people making fun and even a living by vocalizing their plastic surgery experiences, back in the day of Phyllis Diller’s prime such things were not usually spoken of. In her day she was the solo Queen of plastic surgery. Today there is a courtyard of them. For some, her openness about plastic surgery also made her an Ambassador of the surgical specialty. She quipped about aging and beauty frequently with such notables as:

‘I have been done over so many times that no two body parts are the same age.’

‘When I die, God won’t even recognize me.’

‘My photographs don’t do me justice, they look just like me.’

‘I’m in the 14th year of a 10 day beauty plan.’

‘Old age is when your age spots start showing through your gloves.’

‘I have so many liver spots, I ought to come with a side of onions.’

‘I once wore a peekaboo blouse. People would peek and then they booed.’

‘Think of me as a sex symbol for men who don’t give a damn.’

‘My vanity table is a Black & Decker workbench.’

But my favorite will always be:

‘A smile is a curve that sets everything straight.’

For her humor and honesty about plastic surgery, and how it helped improve her self-esteem, put both a smile on her face and countless others around the world.

 Dr. Barry Eppley

Indianapolis, Indiana

Memorial Day is the annual remembrance and recognition in the United States of all members of the Armed Services that have sacrificed for the freedoms that we continue to enjoy today. From Lexington and Concord to Bagdad and Kabul, millions of men and women have given in incalculable ways some of even the ultimate sacrifice. While wars are unfortunate and tragic, they have played major roles in shaping our country.

Just as war as shaped America, it is also heavily responsible for the development of plastic surgery as we know it today. While certain plastic surgery operations can be traced back thousands of years to Egypt and India, they were largely operations of the nose, ear or lip to correct congenital or traumatic injuries. It was not called plastic surgery then and such a term only first appeared in a rhinoplasty textbook in 1818. But it was war that created the need for extensive face and body reconstruction.

The first World War and the doctors involved in it became the cornerstone of modern plastic surgery. The unique and devastating weapons of World War I were considerably advanced compared to earlier conflicts. This was particularly true with machine guns and artillery. Fighting within trenches, soldiers did not realize how quickly a machine gun could catch them in the face or skull as they popped their heads above the line. Shrapnel and exploding artillery shells created major wounds that were both extensive and comminuted. Bones were not just broken, they were shattered. An unimagineable number of shattered jaws, blown-off noses ears and lips, and open skull wounds presented themselves to battlefield doctors with little prior experience.

Surgeons had to create new innovative reconstructive procedures to rebuild faces and limbs of the soldiers both during and after World War I. Techniques such as skin grafting, flap reconstruction, bone grafting and facial prosthetics became well developed with the considerable patient population who needed it. Specialized centers for plastic surgery were created in France and England and some of the classic treatises on plastic surgery were written based on these experiences.

U.S. doctors returned from the war and brought these experiences with them, teaching a new generation of surgeons the exciting field of plastic surgery. This new surgical specialty interest resulted in the formation of the American Society of Plastic Surgeons in 1937 to provide a forum for exchange of ideas and establishing a formal training program for what constitutes a plastic surgeon. Plastic surgery was off and running and, although there have been five other major wars since, none has had the impact that World War I had.

On the surface, it may be hard to see how much of the cosmetic surgery done today has anything to with the reconstructive history of plastic surgery. But the connection is that every cosmetic procedure that I can think of had its beginning in a reconstructive operation. Cosmetic surgery is largely reconstructive procedures modified and refined to elective face and body changes.

War is tragic and most certainly hell for both soldier and civilians involved. But its one benefit is that it creates the need for reconstructive plastic surgery procedures from which the benefits affect both the present and or many future generations as well.

Dr. Barry Eppley

Indianapolis, Indiana

There are actually very few operations in plastic surgery that involve the insertion of a plastic material. This surgical specialty has an artifactual image that is created because it is confused with a modern invention. Plastic surgery as a medical specialty has been around since the 16^th century and its name comes from the Greek word Plastikos meaning to mold or shape. That is certainly much of what plastic surgery attempts to achieve on the human body. Plastic as a material has a much more recent history that only dates back to the 1950s when it was developed. The surgery and the material share the same origin in their name but that is about as closely as they are related.

The father of modern day plastic and cosmetic surgery is credited to Italian surgeon Gaspare Tagliacozzi who lived from 1545 to 1599. He is best known for developing a technique to transfer arm tissue to the face, known as a pedicled arm flap. This was particularly needed for the reconstruction of a disfigured or amputated nose. (this was a common problem with noses lost due to dueling or from syphilis) This technique is seen today in the logo of the American Board of Plastic surgery in which a person is seen with their forearm bandaged up against their nose. He was known for other reconstructive procedures of the eyelids, lips and ears but his nasal  reconstructions remain his signature procedure.

Bullying for school age children and teenagers has reached unprecented awareness recently. While it is a social phenomenon that has gone on forever, many recent examples of internet intimidations and even suicides has made it newsworthy of late. The recent movie release “Bully’ has brought an awareness particularly to adults that brings back unfortunate memories for many and is perhaps why the movie has appeal to more than just those in school. Unlike days of old when bullying may have been limited to school time, there is nowhere to hide in today’s internet and smartphone age.

While bullying occurs for many reasons, physical deformities and differences are a frequent source. It is one thing when a child and teenager know that they are structurally different, but it reaches a malicious and psychosocial altering situation when it is brought to public attention. Whether it is a big nose, ears that stick out or breasts that are too large, such visually apparent features can be a source of torment and intimidation.

Is plastic surgery a solution for bullying when these physical conditions exist? Before bullying reached its current awareness, such plastic surgery procedures have been done for a long time for those children and teenagers whose self-images were affected by them. There is no question that such operations as rhinoplasty, otoplasty, congenital facial deformity surgery (e.g., cleft lip and palate) and breast reduction have psychologically helped many young patients. I have seen and been told by parents of patients that they have become less introverted and shy after their plastic surgery. I can often see it in their eyes and facial expressions that they are feeling better about themselves.

But that does not make plastic surgery a solution for bullying? You can change the physical deformity but you can’t change their social circumstances. Plastic surgery is but one tool, one aspect of the therapy so to speak, in bullying management for the physically affected. In the properly selected patient who has parental support and permission, plastic surgery correction can make an invaluable contribubtion.

This should not be confused with other plastic surgery procedures that do not correct a physical deformity but are done in an effort to alter one’s natural, albeit not desired, body shape. These would be so-called efforts to make one look more thin or shapely. Or to help one have a body that is more like that of some celebrity or model. Breast augmentation and liposuction, while a personal decision for adults, are not what I would consider important self-image surgeries for younger patients to help them escape bullying or criticisms from their peers.

Dr. Barry Eppley

Indianapolis, Indiana