An examination of the phenol-croton oil peel: Part III. The plastic surgeons' role

In Part II, the author focused on the lay peelers' history and success using croton oil-containing phenol peeling recipes. In Part III, the author reviews what was known or should have been known about croton oil and phenol as physicians became keenly interested in face peeling in the mid-1950s. The lay peelers recognized that croton oil was a critical ingredient of the so-called phenol peel while physicians focused on phenol without recognizing the intense cytotoxic effect of croton resin. Physicians have persisted in this systematic error for 40 years. Both dermatology and plastic surgery have shown a remarkable credulity about phenol's action and lack of curiosity about croton oil's action. A hitherto unreferenced and unknown croton oil-containing formula of Adolph Brown, patented in 1959, has been unearthed, preceding Litton's and Baker's formulas in time. The recollections of Litton, Baker, Truppman, and Georgiade shed some light on the interaction between them and the lay peelers and how the formulas were transferred. Other plastic surgeons probably acquired the same knowledge, used it in their practices, but chose not to draw attention to it. None of the physicians credited the lay peelers. Brown, Litton, and Baker each could have published a complete formula, but only Baker did. However, his formula was vastly stronger than the lay formulas but, nevertheless, came to dominate medical peeling for the next 35 years because of its simplicity of preparation. A review of the peel literature reveals many oft-repeated but unsupported dogmas regarding the mode of action of phenol, which have obscured our understanding of the phenol-croton oil peel. Animal studies exist that refute these dogmas, e.g., (1) lesser concentrations of phenol wound more deeply; and (2) phenol has an all-or-nothing action. As well, studies from the early 1980s showed that the presence of croton oil caused much deeper burns than phenol alone. Suggested areas of research that could solve the conundrum of the phenol-croton oil peel are presented.     

An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil

In Part IV of this examination of the phenol-croton oil peel, the author presents peeling solutions using phenol in concentrations between 16% and 50% as the carrier for croton oil. Previously, in Part I, the author showed that phenol alone in concentrations of less than 50% has no significant peeling effect on the skin in the absence of taping. All of these formulas are dependent on the addition of croton oil for their peeling action. A topographic map of the face is presented that divides the face into the zones that the author believes are best treated with different strengths of croton oil. Five patients peeled between late 1992 and late 1995 were chosen as examples to illustrate the effect of different strengths of croton oil between 0.25% and 2.78%. The author has documented their immediate postoperative course photographically to show the effect of the different concentrations. It is clinically apparent that peels using croton oil between 0.25% and 0.5% generally heal within 7 days; peels between 0.6% and 1.0% usually heal within 9 or 10 days, and peels using concentrations higher than 1% heal later and have some risk of pigmentation loss. Peels using croton oil concentrations at 2% and above almost always have pigmentation loss and have healing delays in areas other than the thick skin of the lower nose and perioral area. The practical clinical formulas distributed at the time of the presentation of this article at the 1996 Annual Meeting of the American Society for Aesthetic Plastic Surgery in Orlando, Florida, entitled "Heresy Phenol Formulas--1996," are provided here. These have been used in both the United States and Europe over the past few years. A metric standard for drop size is suggested at 0.04 ml. This relates to the drop size used clinically over the years to measure croton oil. The adoption of this unit will make formulas around the world easier to calculate and compare. The author has produced a metric formula using the suggested standard size drop for croton oil. This uses 35% phenol as the carrier and provides the same range of treatment dilutions as the 1996 "Heresy Phenol Formulas." The need for research into "carriers" and solvents for croton oil is pointed out. Despite what is not known about how it works, the combination of croton seed extract and phenol has been a success story in providing facial rejuvenation from the 1920s to the present. The croton oil-phenol peel in its many formulas still sets the standard for facial rejuvenation.     

An examination of the phenol-croton oil peel: Part I. Dissecting the formula

This article investigates which ingredients are the active ones in the most popular peel formula. The benefits of the "phenol" peel have been attributed to the effects of phenol on the dermis. Baker published a simple peel formula in 1962 that became a classic that has been used since by almost all plastic surgeons and dermatologists. Brown et al., in 1960, passed along a set of dogmas: (1) phenol is the active ingredient; (2) phenol peels more deeply in lower concentrations; and (3) adding a surface tension-lowering agent increases the peel. This article seeks to dissect the Baker formula by removing the croton oil. A patient was peeled serially with 18% phenol, 35% phenol, and 50% phenol solutions containing Septisol (surface tension-lowering agent) but no croton oil. This showed that increasing concentrations of phenol caused more clinical tissue reaction as evidenced by edema and erythema, but no significant dermal injury was seen. USP 88% phenol without Septisol did cause injury to the dermis. To test the effect of croton oil in the formula, the patient's face was peeled with two variations: the perioral area was peeled with 50% phenol to which croton oil was added to a strength of 2.1% and the remainder with 50% phenol without croton oil. The perioral area showed vesiculation, slough, and dermal exposure characteristic of a deep peel requiring 11 days to heal. The remainder of the face treated with 50% phenol without croton oil showed only edema and erythema without significant dermal injury. This experiment shows that the main postulates of Brown et al.--that phenol in lesser concentrations peels more than in higher concentrations and that phenol is the sole agent--are not true. In a fourth peel, a 0.7% concentration of croton oil in 50% phenol was applied to the parts of the face not peeled with croton oil in the third peel. The areas peeled with 50% phenol with 0.7% croton oil healed in 7 days, whereas the treatment with 50% phenol with 2.1% croton oil required 11 days. Deconstructing the Baker formula reveals fallacies in the four-decade-long belief system regarding these peels. The serial peels performed in this study show that increasing concentrations of phenol without croton oil cause increasing skin reaction but insignificant peeling effect. The addition of croton oil to 50% phenol, however, causes a marked increase in the depth of peeling into the dermis. Lowering the concentration of croton oil caused a lesser burn, as evidenced by fewer days to heal. The depth of the peel, therefore, seems to be more dependent on the concentration of croton oil than phenol. This will be further explored in Parts II, III, and IV.     

The financial environment of aesthetic surgery: results of a survey of plastic surgeons

To gather information about aesthetic surgery's current practice structures, competitive environment, patient price sensitivity, and marketing and practice development requirements, a two-page survey was developed and mailed to all 1180 members of the American Society for Aesthetic Plastic Surgery. A total of 632 surveys were returned (response rate of 54.5 percent). Most aesthetic plastic surgeons said they were in solo practice (63.3 percent). More than two-thirds described the marketplace as "very competitive," with 59 percent reporting 25 or more surgeons offering aesthetic surgery in their area. They estimated their patients' average income at $62,800. Nearly all plastic surgeons labeled their patients as "moderately price sensitive" (62.3 percent) or "very price sensitive" (30.6 percent). Similarly, 23.2 percent estimated that they had lost 20 or more patients within the last year for reasons of price. Practice development and marketing efforts represented an average of 7.3 percent of plastic surgeons' working time. Parameters associated with a high percentage of time devoted to these activities were solo practice, percentage of revenue from aesthetic surgery greater than 50 percent, a practice environment designation of moderately or very competitive, and ten or more area surgeons offering aesthetic surgery (p < 0.05). High patient income led to only slight decreases in price sensitivity and did not significantly reduce the amount of time spent on marketing and practice development. Although the rest of the healthcare industry has undergone a period of consolidation, aesthetic surgeons have been able to resist these changes. The results of this survey suggest that the fragmented nature of the aesthetic surgery industry is associated with additional burdens on plastic surgeons. As the aesthetic surgery market becomes more competitive, plastic surgeons may benefit from consolidation to reduce costs and maximize efficiency.     

Staff surgery--the inevitable question

The results of a survey of 450 plastic surgeons regarding the practice of operating on their staff members is presented. An overwhelming majority (85 percent) of responding surgeons do operate on their staff. Whether surgery is a "right" of employment or a "reward" for service was addressed. Seventy-two percent felt surgery was a "reward," while only 8 percent felt it was a "right." The results found complications to be relatively minor but numerous (23.5 percent). The need for an office policy is stressed to help eliminate misunderstandings with other employees, and a model office policy is presented and endorsed.     

Polyurethane implants: a 6-year review of 416 patients

The author reviews 6 years of experience and 416 patients in whom polyurethane implants were used for augmentation and reconstruction of the breast. As with many other plastic surgeons, early use was confined to "salvage cases." Owing to the impressive results, use was extended to routine augmentation. Polyurethane implants are now used exclusively for aesthetic breast surgery. Results are evaluated for replacement of gel capsules and simple and radical mastectomy reconstruction. Gel capsules (Baker stages III to IV), in which prostheses were removed and replaced with polyurethane-covered implants, improved in 29 of 32 patients (87 percent). For reconstruction, placement of polyurethane implants in unscarred situations gives far superior results than following repeated procedures. The incidence of infection is no higher than with gel implants. Removal without capsulectomy was not a problem in most instances. However, on two recent occasions capsulectomy was extremely difficult.     

Differences in breast shape preferences between plastic surgeons and patients seeking breast augmentation

There has been little discussion in the published literature regarding breast shape preferences. This study was conducted to ascertain previously undocumented differences in breast shape preferences between plastic surgeons and patients seeking breast augmentation, with respect to upper-pole contour. Sixty-six respondents, grouped into three cohort categories (plastic surgeons, breast augmentation patients, and lay people), were asked to evaluate a series of 12 nonptotic breast profiles representing a range of upper-pole contours. Five profiles exhibited convex upper-pole contours, five exhibited concave contours, and two exhibited upper poles with flat slopes. A five-point Likert-type scale was used to rate attractiveness, naturalness, how close the shape was to each respondent's personal ideal, and how close the shape was to what the respondent believed was our society's ideal. Statistical comparisons were made among the three cohorts. The plastic surgeon cohort (n = 11) rated concave upper-pole contours significantly higher than did the patient cohort (n = 13) for attractiveness, naturalness, and personal ideal (p < 0.01). For convex contours, the plastic surgeon cohort gave significantly lower scores than did the patient cohort (p < 0.01). The lay category (n = 42) demonstrated preferences intermediate between those of the other groups. There are no known studies in the literature documenting the breast shape preferences of plastic surgeons and their patients. This study suggests that plastic surgeons and patients seeking breast augmentation may have drastically different images in mind regarding what constitutes an attractive, natural, and ideal breast shape. These findings have potential implications for patient treatment and satisfaction.     

Non-song acoustic communication in migrating humpback whales (Megaptera novaeangliae)

Humpback whales are renowned for the complex structured songs produced by males. A second, relatively understudied area of humpback acoustic communication concerns un-patterned sounds known as "social sounds," produced by both males and females. These include vocalizations as well as sounds produced at the surface of the water as a result of surface behaviors ( e.g. , breaching, pectoral slapping). This study describes a portion of the non-song social sound repertoire of southward migrating humpbacks in Australian waters, and explores the social relevance of these sounds. On migration, humpback whales travel in social groups of varying compositions. These social groups are not stable in that humpback whales continually change group composition by splitting from, or joining with, other groups. The results of this study suggest that "breaching" and "slapping" have a communicative function. Other sounds such as "underwater blows" and "cries" were heard mainly in competitive groups while other low-frequency sounds such as "grumbles,""snorts,""thwops," and "wops" may function in intra- or inter-group communication. Particular sounds ("grunts,""groans," and "barks") were almost exclusive to joining pods suggesting a role in social integration. Social sounds in humpbacks may have specific social and behavioral functions relating to social group composition, and the mediation of interactions between these social groups.     

Victor von Bruns (1812-1883) and his contributions to plastic and reconstructive surgery

Victor von Bruns was an active surgeon in Germany during the nineteenth century. His work is accompanied by many illustrations, and a selected few are presented in this survey. His original contributions to plastic and reconstructive surgery are notable, mainly in lip and cheek reconstruction. These are still valid today and have been adopted by many plastic surgeons. His books dealt not only with plastic surgery, but with almost every surgical event, such as amputation, larynx surgery, galvanosurgery, and war surgery. His publications and illustrations give an excellent picture of the advances made by him and other plastic surgeons during the second half of the nineteenth century, thus making him an important contributor to the renaissance of plastic surgery.     

Improved methods for using glass coverslips in cell culture and electron microscopy.

For many applications, cells or tissue must be cultured on an optical surface of high quality. For such applications laboratories often prepare "special dishes," which are made by affixing a glass coverslip beneath a hole in a plastic petri dish bottom. In this report, we offer an improved method, using Parafilm as a dry mount adhesive, for the preparation of special dishes, and show that the resulting dish is non-toxic to neurons in culture. The Parafilm bond is stable at 60 degrees C, permitting electron microscopy resins to be poured directly into the dishes and cured. The glass coverslip can be readily removed from the cured resin mechanically. The techniques we describe offer time-saving and reliable improvements for the use of glass coverslips in cell culture and electron microscopy.     

When an adult female seeks ritual genital alteration: ethics, law, and the parameters of participation

Ritual genital cutting for women, a common practice in Africa and elsewhere around the world, remains dangerous and controversial. In recent years, a 14-year-old girl living in Sierra Leone exsanguinated and died following a ritualistic genital cutting. Hoping to avoid that fate, women with backgrounds that accept ritual genital cutting may, when they reach majority age, ask plastic surgeons to perform genital alterations for cultural reasons. Although plastic surgeons routinely perform cosmetic procedures, unique ethical and legal concerns arise when an adult female patient asks a surgeon to spare her the tribal elder's knife and alter her genitalia according to tradition and custom. Misinformation and confusion about this issue exist. This article explores the ethical and legal issues relevant to this situation and explains how the thoughtful surgeon should proceed.     

Textured-surface saline-filled silicone breast implants for augmentation mammaplasty

The earliest silicone breast implants were smooth-surface, silicone rubber devices filled with either silicone gel or saline. Because of persistent problems with capsular contracture, polyurethane-covered silicone implants were developed as an alternative. Particularly in the short run, these alternatives proved highly successful at reducing the incidence of capsular contracture. By 1990, polyurethane-covered implants were rapidly becoming the preferred implant choice of many plastic surgeons, but for legal, regulatory, financial, and safety reasons they were withdrawn from the market by Bristol-Myers in 1991. Meanwhile, during the late 1980s, surface texturing and improved materials became available on other silicone breast implants and expanders. Most studies suggest that textured-surface silicone gel-filled implants, saline-filled implants, and tissue expanders have less frequent capsular contracture than their smooth-surface counterparts.     

Discount cosmetic surgery: industry trends and strategies for success

Discount cosmetic surgery is a topic of interest to plastic surgeons. To understand this trend and its effects on plastic surgeons, it is necessary to review the economics of cosmetic surgery, plastic surgery's practice environment, and the broader business principles of service industries.Recent work looked at the economics of the plastic surgery market. This analysis demonstrated that increased local density of plastic surgeons was associated with lower adjusted fees for cosmetic procedures. A survey of plastic surgeons about their practice environment revealed that 93 percent categorized the majority of their patients as very or moderately price-sensitive. Fully 98 percent described their business climate as very or moderately competitive and most plastic surgeons thought they lost a sizable number of cosmetic patients within the last year for reasons of price.A standard industry analysis, when applied to cosmetic surgery, reveals the following: an increased number of surgeons leads to lower fees (reducing their bargaining power as suppliers), patients are price-sensitive (increasing their bargaining power as buyers), and there are few barriers to entry among providers (allowing potential new entrants into the market). Such a situation is conducive to discounting taking hold-and even becoming the industry norm.In this environment, business strategy dictates there are three protocols for success: discounting, differentiation, and focus. Discounting joins the trend toward cutting fees. Success comes from increasing volume and efficiency and thus preserving profits. Differentiation creates an industrywide perception of uniqueness; this requires broadly positioning plastic surgeons as holders of a distinct brand identity separate from other "cosmetic surgeons." The final strategy is to focus on a particular buyer group to develop a market niche, such as establishing a "Park Avenue" practice catering to patients who demand a prestigious surgeon, although this is likely a small segment of the overall patient population. Plastic surgeons that buck the trend toward discount cosmetic surgery must take concrete and potentially costly steps to implement a plausible strategy for distinguishing their practices within the crowded cosmetic surgery market.     

Fatal outcomes from liposuction: census survey of cosmetic surgeons

Troubling reports of adverse outcomes after liposuction prompted a census survey of aesthetic plastic surgeons. All 1200 actively practicing North American board-certified ASAPS members were polled by facsimile, then mail, regarding deaths after liposuction. Patient initials together with case summaries precluded data replication yet assured patient anonymity and preserved surgeon privacy. Incomplete returns or ambiguous findings were authenticated, where feasible, by direct follow-up. Total number of lipoplasties performed by plastic surgeons was interpolated from the ASPRS procedure database for the survey time frame of 1994 to mid-1998. Lacking reliable annual case volume estimates, deaths from lipoplasties performed by non-ABPS surgeons were excluded from the actual mortality rate computation but were included in cause-of-death ranking statistics. Responding aesthetic plastic surgeons (917 of 1200) reported 95 uniquely authenticated fatalities in 496,245 lipoplasties. In this census survey, the mortality rate computed to 1 in 5224, or 19.1 per 100,000. A virtually identical 20.3 per 100,000 mortality rate was obtained in a 1997 random survey commissioned by the parent society. Pulmonary thromboembolism remains as the major killer (23.4+/-2.6 percent); lacking consistent medical examiners' toxicology data, the putative role of high-dose lidocaine cardiotoxicity could not be ascertained. Where so stated, many deaths occurred during the first night after discharge home; prudence suggests vigilant observation for residual "hangover" from sedative/anesthetic drugs after lengthy procedures. Taken together, these two independent surveys peg the late 1990s mortality rate from liposuction at about 20 per 100,000, or 1 in every 5000 procedures. Set beside the 16.4 per 100,000 fatality rates of U.S. motor vehicle accidents, liposuction is not an altogether benign procedure. We do not have comparable mortality data for lipoplasties performed by non-ABPS-certified physicians.     

"De-epithelization" and dermal pedicles.

Biopsy specimens from 38 "de-epithelized" dermal pedicles were examined microscopically. There was considerable variation in the depth of the plane among surgeons, procedures, and even between specimens from two sides of a bilateral procedure done by the same surgeon. Usually, the "de-epithelization" removed all the epidermis plus the upper layer of dermis containing the pilosebaceous apparatus. The significance of this finding as related to the future development of epidermal inclusion cysts is uncertain. Also, it brings into question the importance of "the dermal plexus circulation," which many have thought to be critical for viability of the nipple.     

Managed care's attempts to capture aesthetic surgery

Managed care organizations recently have attempted to add aesthetic surgery to their line of available services. To better understand the challenges posed by these actions, all members of the American Society for Aesthetic Plastic Surgery were surveyed about managed care overtures to aesthetic plastic surgeons, their responses, and the likely responses of their patients. The goal was to examine both the supplier and consumer ends of the aesthetic surgery market to determine the likely effects of managed care's attempts to capture aesthetic surgery. A total of 632 plastic surgeons returned the surveys (response rate, 54.5 percent). Twenty-two percent reported being approached by managed care organizations about joining a panel of aesthetic surgeons. Approximately one-quarter of the plastic surgeons said they would participate in aesthetic surgery panels developed by managed care organizations. Characteristics significantly associated with willingness to participate were solo practice structure, a low percentage of practice revenues from aesthetic surgery, and a very competitive practice environment. Plastic surgeons believed that their colleagues would be even more willing to acquiesce to managed care aesthetic surgery; more than one-third said that 25 to 50 percent of their colleagues would join, and nearly one-third thought that more than half would participate. Plastic surgeons believed that many of their patients would also participate in managed care aesthetic surgery. Twenty-four percent thought that more than half of their patients would choose an aesthetic surgeon through their managed care organization if that organization developed a network for aesthetic surgery. This figure increased to almost 40 percent if the organization would deny coverage for complications resulting from nonpanel surgeons, and to 41 percent if the organization would offer price discounts. This survey shows that most plastic surgeons are against managed care aesthetic surgery. But it also shows that some plastic surgeons will participate, and that most plastic surgeons think many of their colleagues and patients will do likewise. This means that managed care organizations have the potential to make inroads in aesthetic surgery on both the supplier and consumer ends of the market. To prevent managed care from capturing aesthetic surgery, plastic surgeons must anticipate the likely business strategy of managed care. To this end, they must understand the steps involved in the creation of a new service business and offer organized countermeasures against each of them.     

Vilray P. Blair, his surgical descendants, and their roles in plastic surgical development.

Perhaps one of the most historically well-known plastic surgeons is Vilray P. Blair. As commander of the U.S. Army corps of head and neck surgeons during World War I, he became well known for his work in posttraumatic reconstruction. Blair's efforts in the early part of this century helped to develop plastic surgery as a distinct surgical subspecialty in the United States. His prowess as a surgeon allowed him to build one of the largest plastic surgery centers in the country and to train many of the top young American surgeons. Blair excelled as a teacher. He produced academic surgeons such as James Barrett Brown and Bradford Cannon, who took the lead in the care of wartime injuries during World War II. At Valley Forge General Hospital, Blair's trainees dedicated themselves to the reconstruction of injured patients and trained other young plastic surgeons in the care of postwar trauma. This exceptional level of patient care resulted in the U.S. government recognizing plastic surgery as a subspecialty following World War II. Since that time, Blair's surgical descendants at Washington University have led the country in the development of new training concepts and ideals and have gone on to become leaders in plastic surgery worldwide.     

Expert systems in treating substance abuse.

Computer programs can assist humans in solving complex problems that cannot be solved by traditional computational techniques using mathematic formulas. These programs, or "expert systems," are commonly used in finance, engineering, and computer design. Although not routinely used in medicine at present, medical expert systems have been developed to assist physicians in solving many kinds of medical problems that traditionally require consultation from a physician specialist. No expert systems are available specifically for drug abuse treatment, but at least one is under development. Where access to a physician specialist in substance abuse is not available for consultation, this expert system will extend specialized substance abuse treatment expertise to nonspecialists. Medical expert systems are a developing technologic tool that can assist physicians in practicing better medicine.     

The effect of increased plastic surgeon supply on fees for aesthetic surgery: an economic analysis

The size of the plastic surgery workforce has important effects on the financial environment of the specialty. Economic theory predicts that increasing the area supply of surgeons performing aesthetic surgery will result in lower fees for their services. This study tested that theory in the actual aesthetic surgery marketplace. The study examined the ratio of plastic surgeons to the general population of several states. It then traced the aesthetic surgery fees resulting from different densities of area plastic surgeons. This information was economically analyzed to project the fee effects of possible future changes in the number of practicing plastic surgeons. For the states of New York, California, and Texas, there is a proportional decrease in fees as the density of plastic surgeons increases. For example, New York has 34 percent more plastic surgeons proportionally than Texas, and its fees are 30 percent lower in real dollars. Economic analysis can project the fee effects of changing the supply of surgeons performing aesthetic surgery. The analysis reveals that a 30 percent national increase in the supply of plastic surgeons would lower fees by approximately 32 percent. Similarly, if the number of plastic surgeons increases by 50 percent, fees will decrease by approximately 53 percent. However, these fee effects can be mitigated by expanding the demand for aesthetic surgery. In conclusion, the size of the plastic surgery workforce has profound effects on the fees paid for aesthetic surgery, and the magnitude of these effects can be understood, predicted, and optimized using the tools of economics.     

Cosmetic surgery in times of recession: macroeconomics for plastic surgeons

Periods of economic downturn place special demands on the plastic surgeon whose practice involves a large amount of cosmetic surgery. When determining strategy during difficult economic times, it is useful to understand the macroeconomic background of these downturns and to draw lessons from businesses in other service industries. Business cycles and monetary policy determine the overall environment in which plastic surgery is practiced. Plastic surgeons can take both defensive and proactive steps to maintain their profits during recessions and to prepare for the inevitable upturn. Care should also be taken when selecting pricing strategy during economic slowdowns.