Article: Breast fat grafting gets thumbs up!

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San Diego — Officials of Cytori Therapeutics, based here, say British surgeons have successfully used the company’s adipose-derived regenerative cell (ADRC) fat grafting procedure — which the company calls RESTORE — in reconstructive breast surgery, Medical News Today reports. 

The company says clinical outcomes were reported at the Association of Breast Surgery Conference in Manchester, England, earlier this month. The procedure was separately investigated in Cytori's own RESTORE 2 trial, according to Medical News Today. 

The British surgeons’ report results from an independent, prospective study of 23 patients who received ADRC-enhanced fat grafting for the correction of breast-contour defects following cancer treatment or benign conditions including implant complications, using Cytori’s Celution System. Patients were treated between September 2008 and November 2010 with follow-up between three months and two years. The results showed that 19 of the patients, or 82 percent, reported good to excellent results, with a mean satisfaction score of 5.1 (1 being worst, 6 being best). 

The results further showed a high level of investigator satisfaction, with a mean satisfaction score of 4.3. Study findings demonstrated a low complication rate. 

Overall, the company says, the study results suggest the RESTORE procedure is a viable breast reconstruction option.

By: Bill Gillette
Cosmetic Surgery Times E-News

Procedure Freezes Fat Cells To Flush Fat!

Dr. Z wants to share this article from KTSN News Channel 9:

 View full article and video: http://bit.ly/lve81l

EL PASO- Most of us have that annoying area of fat we can't seem to get rid of no matter how much we diet or exercise. While liposuction is an expensive and sometimes painful solution, a new technique has helped dozens of people in the Borderland at a fraction of the price and in an hour's time. It's called "cool sculpting" and the way it works is by freezing your fat cells.

“I'm going to Hawaii in June, so that's why I started kind of early to fit into that bikini for Hawaii,” says Alicia Revelez.

Even though she diets and works out, Revelez said she could not get rid of some bulgy areas like her love handles and stomach. The mother of two didn't want to get liposuction because of the down time and recovery involved, but then she heard of a new procedure.

“This machine is the Zeltiq apparatus. It performs a procedure called cool sculpting,” says Dr. Lyle Weeks.

Dr. Weeks, with Cosmetic Surgery & Laser Center in West El Paso says the procedure has become increasingly popular since his office first started doing "cool sculpting" in December.

“The technology is based on the fact that fat freezes at a higher level than water. This enables us to freeze fat, without freezing the skin where there's a lot of water,” says Weeks.

The frozen fat cells are broken up in the body and flushed out. “Fat is then disposed of by the body, just like a normal fat cell that's outlived its usefulness in the body. It's absorbed and carried away,” says Weeks.

The procedure takes about an hour. First, patients are weighed, marked and photographed. Then, a gel to protect the skin is placed on the area to be treated. The technician then places the Zeltiq applicator, which is about the size of a shoe over the area to be treated.

“It's a little suction. Like you know, the vacuum cleaner, like when it gets you,” says Revelez after the Zeltiq applicator was placed around her abdomen.

So how cold is it? “Cool, not cold cold, just cool,” says Revelez.

After an hour, the patient gets a vigorous massage to help the fat cells break up. Dr. Weeks asks patients to lose one pound over the next three months. “That seems to, for some reason, greatly enhance the results of the treatment,” says Weeks.

Dr. Weeks say there are many advantages to cool sculpting over liposuction. “The advantage of this is, it's extremely effective for small areas. It's very safe. It's essentially painless for most people and it's cost-effective.”

It does take one to two months to see the results following treatment. Reveles had her love handles treated in March and says her friends have taken notice.

“They've noticed a difference and they ask me if I’m on a diet and I’m like, "No.” And I told them about this procedure,” says Revelez. “My pants fit different. My clothes fit totally different.”

Reveles says she loved the results so much she came back to do her stomach.

“It's amazing. It's great. You won't see immediate results but you'll start seeing results in about a month and you drop the fat. You won't see the little bulges anymore.”

The procedure is not effective with obese patients. The ideal candidate is someone who is 20 lbs. or less overweight.

By Oralia Ortega - Main Anchor

Wednesday, May 25, 2011 - 3:00pm

New home-use laser wrinkle remover approved by FDA

Dr. Z wants to share this piece from KENS5.com:

Watch this video: http://bit.ly/jluEzw 

For some, fighting wrinkles with the use of a home laser sounds dangerous, but the FDA recently approved just such a device.

It's primary target: crow's feet.

The PaloVia Skin Renewing Laser is the only FDA cleared take-hoe laser device on the market so far.

According to the instructions, after daily use for a month, you will see natural looking, but dramatic results.

Dr. David McDaniel of the McDaniel Laser and Cosmetic Center calls it a breakthrough product.

"The PaloVia device goes deeper in the skin where wrinkles are formed and helps stimulate fresh new collagen whereas things like Retin-A, retinoids, creams and lotions typically don't do that," says McDaniel.

Until now, plumping up eye wrinkles required a visit to the doctor's office and two to four treatments with a large fractional laser.

The laser doctors use is much stronger than the home-use variety. It has the ability to penetrate much deeper. But the PaloVia laser can make up for its lack of power through repetition.

"Nine out of ten people in the original studies showed visible improvement in 30 days," says McDaniel.

But, to get the targeted crow's feet area, puts the laser close to the eyes. Is it safe?

"The PaloVia device knows if it's in contact with your skin. It also knows if it's sealed for light and when it's sealed," explains McDaniel. "A little blue light comes on and it will allow you to fire it. If you're not sealed, it can't fire."

Besides a little redness after each treatment, Dr. McDaniel says people who use the laser are OK.

Article: Sugary Band-Aid May Help Heal Post-Operative Tissue

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Gel Developed From Same Compound Found in Spray Tanning Lotion

NEW YORK -- A compound found in sunless tanning spray may help to heal wounds following surgery, according to new results published by plastic surgeons from NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York City and biomedical engineers at Cornell University in Ithaca, N.Y., where the novel compound was developed.

Results published today in the Proceedings of the National Academy of Sciences show that a sticky gel composed of polyethylene glycol and a polycarbonate of dihydroxyacetone (MPEG-pDHA) may help to seal wounds created by surgery.

Procedures to remove cancerous breast tissue, for example, often leave a hollow space that fills with seroma fluid that must typically be drained by a temporary implanted drain. "This is an unpleasant side effect of surgery that is often unavoidable," explains Dr. Jason Spector, co-author of the study and plastic surgeon at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

The gel could potentially be used in all different reconstructive surgeries to prevent seroma formation. "The new substance would act to glue together the hole left behind to prevent seroma buildup," says Dr. Spector.

DHA is a compound that sticks to compounds in biological tissues, called amines. The sticky properties of DHA are what allows sunless tanner to adhere to the skin without being wiped off. However, it is biodegradable and water soluble as well, which means that the compound does not stay tacked onto the body's tissues forever. Currently used "bio-glues" are made from animal products and take a long time to degrade in the body -- both factors that raise the risk of infection.

"DHA is a compound that is naturally produced in the body," explains Dr. David Putnam, the study's senior author and a biomedical engineer from Cornell University's Department of Biomedical Engineering and School of Chemical and Biomolecular Engineering. "The glue is broken down, or metabolized, and then safely removed by the body."

Dr. Putnam's lab and his collaborators work to create safe, synthetic compounds from chemicals found in nature. DHA is an intermediary compound produced during the metabolism of glucose, a sugar used by the body for fuel.

To create the new compound, MPEG-pDHA, Dr. Putnam and his lab first bound the single molecule monomer of DHA, which is highly reactive, to a protecting group molecule, making it stable enough to manipulate. This allowed the engineers to bind the monomers together to form a polymer, or chain of molecules, along with MPEG. Doing so allows the polymer gel to be injected through a syringe.

"Making a polymer from DHA has eluded chemical engineers for about 20 years," says Dr. Putnam.

Now in gel form, the compound has the ability to stick tissues together, preventing the pocket from filling with seroma fluid, like an internal Band-Aid, explains Dr. Putnam. The researchers found that the gel prevented or significantly lowered seroma formation or fluid buildup in rats that had breast tissue removed.

"The next step would be to test the gel on larger animals and then in clinical trials in human surgical cases," says Dr. Spector.

Previous results, published by Drs. Putnam and Spector, in the August 2009 issue of the Journal of Biomedical Materials Research, showed that the gel also prevented bleeding in a rat liver.

"This is another aspect of the compound that would be greatly beneficial if proven to be applicable in humans," says Dr. Spector. "The gel could speed the healing and decrease bleeding within the body."

This research was supported in part from a National Science Foundation CAREER Award, a grant from the Morgan Tissue Engineering Fund, an Early Career Award from the Wallace H. Coulter Foundation, and the New York State Center for Advanced Technology.

Co-authors of the study include Dr. Peter Zawaneh from Cornell University, Dr. Sunil Singh and Dr. Peter Henderson from Weill Cornell, and Dr. Robert Padera from the Department of Pathology at Brigham and Women's Hospital.

For more information, visit www.nyp.org and www.med.cornell.edu.

Using your Own Body Fat for Cosmetic Procedures

Dr. Z wants to share this article with you that shows the Body Jet System used in his office for lipo, as well as Biolife (where fat is sent to for storage) - featured at the Fat Grafting Conference:

 It is considered a natural way to enhance your face and body. And now this procedure is growing in popularity.

Technology is changing not only cosmetic procedures, but medical treatments that could one day, also be the answer to curing some medical and genetic illnesses.

Tina LeBoeuf, 46, of Houma, had two life changing experiences. The first was her choice. After three children, she had a tummy tuck and breast implants. But after she healed something happened she had no control over.

"It was really supposed to be a renewal of life and an exciting time in my life. But two months after I felt a lump after the swelling went down. And after they did a biopsy, they told me I had breast cancer," remembers LeBoeuf.

The last year was tough on her with 16 rounds of chemo, 25 of radiation to fight her Stage 3 diagnosis.

Surgery completely removed the internal breast tissue. An expander was inserted to keep the breast skin from collapsing and scaring down.

"It was very hard doing work and still being a mom and going through cancer. But I was determined to not let the cancer win," LeBoeuf declared.

Now she is doing something new in medical technology that could be used for more natural, anti-aging procedures, such as a liquid face lift, and even in the future to cure serious illness.

"The mood in the country now is people want to do what's natural for them and nothing can be more natural than doing an improvement to yourself, be it reconstructive or any type of a cosmetic deformity than using your own fat," said Ray Zale, Senior Vice President of Development for BioLife Cell Bank.

What's new is that your fat, removed through liposuction, can now be stored for later cosmetic or medical use. BioLife Cell Bank in Dallas is growing daily with hundreds of patients in the U.S. and Canada storing their fat. That tissue can be sent back to patients for cosmetic procedures all over the body. Some examples are: to build up a sagging face with or without a face lift, sagging earlobes, breasts with or without implants to make them fuller, softer with a more natural cleavage. It can also be used for a buttocks lift. In men, it can be used for the look of biceps, chest and calf muscles. Also in the hands, the lips and even to fix old scars and depressions from liposuction.

Plastic surgeons recently came to New Orleans to learn the latest in fat grafting at a medical conference.

"Patients are coming in. They are asking for it. There's a lot of buzz about it both in the medical literature as well as in the lay press and I think it's something that in the next five years is really going to grow immensely," said Dr. Larry Weider, a plastic surgeon in Dallas, Texas who came to New Orleans for the conference.

And that is how Metairie plastic surgeon Dr. Kamran Khoobehi is helping LeBoeuf. In the O.R., he is taking fat from her lower body. Some will be mailed off to BioLife Cell Bank. The rest will be used to rebuild the inside of the breast that had cancer. It will put around her new breast implant so that it's more natural but also to act as a cushion between the breast implant and skin that is very delicate after being damaged by radiation treatments.

"Using the fat grafting gives another option for the patients that don't want to through the breast reconstruction," Said Dr. Khoobehi, The Chief of Plastic and Reconstructive Surgery at LSU Health Sciences Center.

But there's another benefit. As research advances, her own stored fat could one day be used to heal and even cure medical and genetic conditions.

"Your adult stem cells are the highest concentration in your fat than in any other part of the body by a magnitude of 500 times when you compare it to blood or bone marrow," explained Zale.

For LeBoeuf, her fat with its stem cells put around her new implant, could keep that thin radiated breast skin from tearing down.

"The studies from Italy coming that using the fat grafting to the radiated tissue, you see regeneration of the tissue," noted Dr. Khoobehi.

With her fat in a bank, any future procedures would not require surgery in the O.R., just office injections. And Dr. Khoobehi has developed low pressure techniques to collect the fat by hand and through the water jet machine that keep the fat cells intact and living for a long time when grafted back into the body.

Some doctors think the cost of banking is worth it.

"When you look at the cost of using fillers and other products that are temporary, that have to be reinjected every six months or nine months verses using your own fat and having it available to you, and having it last much longer than some of these fillers that are available, I think it makes sense financially," said Dr. Weider.

Now LeBoeuf is looking towards her 25th anniversary.

"We're going to go to Hawaii and renew our wedding vows," her husband Dwayne said with a smile.

"I am definitely holding him up to that trip to Hawaii for my anniversary," she said from her pre-op bed.

The cost for the first year of processing, preserving and storing the fat is around $1,700. Every year after that is around $200. The cost of processing the stem cells is extra.

By: Meg Farris / Medical Reporter; wwltv.com New Orleans, LA.

IV Skin Whitener Could Be Deadly!

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Manila, Philippines — The Food and Drug Administration of the Philippines has issued an advisory that warns of the potentially serious risks of using the popular intravenous skin whitener glutathione (Glutathione IV), GMA News Online reports.

 Citing reports received by the agency, Director Suzette Lazo, M.D., is quoted in the advisory as saying, “The alarming increase in the unapproved use of glutathione administered intravenously as a skin-whitening agent at very high doses is unsafe and may result in serious consequences to the health of users.” 

According to Dr. Lazo’s statement, adverse reactions include the deadly Stevens-Johnson syndrome and toxic epidermal necrolysis; thyroid function derangement; suspected kidney dysfunction, potentially resulting in kidney failure; and severe abdominal pain in a patient receiving twice-weekly glutathione administered intravenously. 

Glutathione is a liver-generated compound that plays a role in antioxidant defense, metabolism and regulation. It may induce a skin-whitening effect by inactivating the enzyme tyrosinase, which is needed in melanin production and converts the pigment to the lighter pheomelanin. Dr. Lazo noted that this claim has been disputed. 

“When administered orally, (glutathione) is hydrolyzed by the gastric juices and further undergoes degradation by the liver enzyme, and the resultant bioavailability is low,” she said. “Intravenous administration delivers very high doses directly into the systemic circulation and may overload the renal circulation.”

By: Bill Gillette
Cosmetic Surgery Times E-News

Great Article to share- Study: Hair Stem Cells Communicate

Dr. Z wants to share this great article from:

Los Angeles — Researchers here say they have discovered how hair stem cells in mice and rabbits communicate with each other to encourage coordinated regeneration — a finding that could lead to a cure for alopecia, Medical News Today reports.

Working with mathematical biologists from the University of Oxford, England, researchers from the University of Southern California’s Keck School of Medicine analyzed month-to-month changes in the hair-growth patterns on shaved mice and rabbits. The changes indicate that hair follicle stem cells cycle between active and quiescent states.

Medical News Today quotes Keck School pathology professor and lead investigator Cheng-Ming Chuong, M.D., as saying, “The results are totally surprising. There is complex coordination not apparent to the naked eye.” That coordination, Dr. Choung added, is the ability of the large hair stem cell population to communicate with each other to generate robust hair growth.

According to the study, improving the environment for this kind of stem cell communication could lead to a cure for alopecia, which occurs in humans partially because stem cells in human hair follicles have lost the ability to communicate with each other.

The study’s results are so promising that USC’s Stevens Institute for Innovation has applied for a patent on the composition and method to modulate hair growth. The study, which was funded by the National Institutes of Health, appears in the May 3 issue of the journal Science Signaling.

May 19, 2011
By: Bill Gillette
Cosmetic Surgery Times E-News

Indoor Tanners Follow Moms' Lead

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Schaumburg, Ill. — A large proportion of Caucasian teenage girls and young women who use tanning beds also have mothers who tan indoors, a new survey finds. 

According to the American Academy of Dermatology (AAD), tanning bed users were more than twice as likely to have a family member who also tans indoors (65 percent) compared to their non-tanning peers (28 percent). Indoor tanners were four times as likely (42 percent) to report that their mothers use tanning beds compared to non-indoor tanners (10 percent). 

The survey also found that the vast majority of indoor tanners (94 percent) reported that their parents did know that they were using or had used a tanning bed. 

Respondents who had used tanning beds in the previous year were nearly twice as likely to indicate feeling peer pressure to be tanned (49 percent) compared to non-tanning bed users (28 percent). The vast majority of indoor tanners (96 percent) also reported having friends who tan either indoors or outdoors. 

More than 3,800 white, non-Hispanic females ages 14 to 22 responded to a nationwide online survey to determine their tanning knowledge, attitudes and behavior, according to the AAD. The survey was conducted from Dec. 28, 2010, to Jan. 11, 2011.

May 11, 2011
By: Bill Gillette
Dermatology Times E-News

Vermont Passes Plan for Universal Healthcare

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May 5, 2011 — In a 94 to 49 vote today, the state House in Vermont sealed the deal on a bill to eventually create a publicly financed universal healthcare system that some supporters dub "single payer."

With the state Senate already having given its approval last week, the bill will now go to Vermont Governor Peter Shumlin, who is eager to sign it into law.

Today's action completes the second round of voting for the bill. Both chambers of the Vermont legislature had approved earlier versions, but a House–Senate conference committee had to iron out minor differences and send the bill back for additional votes.

The legislation establishes a state health insurance exchange — mandated by the new healthcare reform law called the Affordable Care Act (ACA) — through which individuals and small businesses can purchase coverage. The bill envisions this exchange becoming a publicly financed health plan called Green Mountain Care that is available to all Vermont residents. Proponents of Green Mountain Care have touted it as a single-payer system, but the bill allows individuals covered under the state plan to buy supplemental policies from private insurers. In addition, individuals can keep the insurance coverage they already have.

For these and other reasons, a group called Physicians for a National Health Program contends that the Vermont bill falls short of a true single-payer model. Although Governor Shumlin disagrees with that assessment, lawmakers removed the expression "single-payer system" from the bill and replaced it with "universal and unified health system."

Under the ACA, states can obtain waivers to opt out of federal healthcare reform requirements and enact equivalent statewide reforms similar to the kind underway in Vermont beginning in 2017. Shumlin and others hope that Congress passes a pending bill that would move the opt-out date to 2014. States securing waivers will receive the ACA funding that they are otherwise entitled to. Nevertheless, Vermont lawmakers still face the job of devising a comprehensive plan to pay for their new system.

Vermont's roadmap for universal healthcare coverage and a publicly financed health plan has received mixed reviews from physicians in that state. According to a survey conducted by Democratic state Rep. George Till, MD, who voted for the legislation, 44.2% of physicians support the single-payer concept, and 45.6% oppose it. Opponents tend to be specialists, who are more likely than primary care physicians to view the new system as financially unattractive. In addition, 28.4% of physicians say they would likely stop practicing medicine in Vermont if the proposed reforms come to fruition.

By Journalist: Robert Lowes

Freelance writer, St. Louis, Missouri

FDA Panel Gives Thumbs Up to Restylane as Lip Enhancer!!

Dr. Z wants to share another great article from Medscape:

April 27, 2011 — Today, the US Food and Drug Administration's General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee recommended the injectable wrinkle-filler Restylane (Medicis Aesthetics Inc) for use as a lip enhancer.

Restylane, an injectable gel composed of hyaluronic acid, is indicated for mid- to deep-dermal implantation to correct moderate to severe facial wrinkles and folds, such as nasolabial folds. The company is seeking to amend the product's indication to include submucosal implantation for lip augmentation.

The panel voted 6 to 0 (1 abstaining) that Restylane for lip augmentation is generally safe and effective for this purpose and that the benefits outweigh the risks.

The FDA still has to make a final decision on Restylane injectable gel for lip augmentation, but the agency usually follows the advice of its advisory panels, which consist of outside experts.

The panel heard an overview of data from the pivotal 12-center study of 180 patients randomly assigned to lip augmentation with Restylane injectable gel or to no treatment.

After weighing the evidence of effectiveness, "the panel generally believes that Restylane has been shown to be effective for lip augmentation," Susan Galandiuk, MD, professor of surgery, University of Louisville in Kentucky, who chaired the panel, said.

In general, treatment emergent adverse events in the study were common, transient, and mild. No unanticipated adverse events occurred; anticipated adverse events included bruising, redness, swelling, pain, tenderness, and itching.

After weighing the evidence on safety, "the panel generally believes that Restylane for lip augmentation is generally safe," Dr. Galandiuk said. Panel member Michael J. Miller, MD, chief of the Division of Plastic Surgery, The Ohio State University, Columbus, noted that, overall, adverse effects are "self-limited and most [patients] came back for further treatment."

FDA statistician Alvin Van Orden noted that in the pivotal study on Restylane for lip augmentation, a "wide range of volume" of Restylane gel was used and an increase in injected volume did not predict increased effectiveness; "volume injected was not a predictor of lip fullness in any model," he said, "but a higher injected dose does appear to increase safety concerns."

Summing up the panel's discussion on this issue, Dr. Galandiuk said that in general, "the panel has no significant concern regarding the lack of correlation between the injected dose and the change in lip fullness, and the panel does not feel a need to cite a maximum injectable dose."

However, she said, the panel recognizes that the product will have "widespread applicability to numerous types of physicians, and possibly dentists, and feels there is a need to set some type of limit for an individual dose per lip and that there should be training guidelines for physicians and users of this product."

Data on Restylane as a lip enhancer in people with darker skin types and men are limited. However, panel consensus was that no additional premarket studies are necessary in these 2 populations.

Several panel members also had "philosophical" concerns about its use in younger patients age 18 to 22. Only 4 patients in the pivotal 180-patient study were in this age group.

The majority of the panel also do not feel that a postmarketing study is required, but several members believe that a registry should be created to follow outcomes, particularly in younger patients.

During the public comment portion of the meeting, Gloria Duda, MD, board-certified plastic surgeon from McLean, Virginia, who was representing the American Society for Aesthetic Plastic Surgery, noted that Restylane is commonly used off-label to augment and contour the lips, and she encouraged the panel to support its use for this indication.

Lip augmentation is a "very frequently" requested procedure, Dr. Duda said, and, in her experience, the results are "immediate and reproducible and the risks with hyaluronic acid are minimal."

"I perform over 120 lip augmentations per year with no complications and 95% retention with return visits at 8 to 12 months for repeat procedures," Dr. Duda said.

General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee. Meeting held April 27, 2011, in Gaithersburg, Maryland.

Article by: Megan Brooks

From Medscape Medical News

 

Article: Should People with Unhealthy Lifestyles Pay Higher Insurance Premiums? (Part 4)

We hope you enjoy the last part of this recent article from Medscape on the topic and debate of whether people with unhealthy lifestyles should pay higher health insurance premiums.  - Dr. Z

Article: Part 4

By: David R. Buchanan

A number of criteria have been proposed by Dubois and other analysts, which offer reasonable grounds for striking an ethically appropriate balance between completely ignoring unhealthy behaviors and appreciating the many barriers that make it difficult for individuals to live a healthy lifestyle. Four proposed standards help to inform the discussion.

Feiring (2008) and Pearson and Lieber (2009) propose that differentiated plans should be imposed only prospectively for voluntarily refusing to take any action to change one's unhealthy behaviors. With this standard, people would not be charged more for coming into a plan being overweight or smoking but for stating that they are not willing to try to do anything about them. Applying this standard would recognize that health status is patterned by social position while acknowledging that it is not "determined," that is, that the majority of poor people do not smoke, are not obese, do not drink excessively, and have some physical activity in their lives (arguably, with some quibbling at the margins), and therefore, that it is reasonable to ask others in the same position to do the same. This standard entails two stipulations: first, that the proposed voluntary action that would demonstrate the good faith effort to be a contributing member to the collective goal of using limited resources prudently is accessible, and second, that it is the effort, not the outcome, that counts. It is sufficient that the member enroll in a smoking cessation program or weight loss program and not necessary that they achieve abstinence or a BMI of 25 to avoid being penalized.

Second, members should be offered a range of options to fulfill their obligation to contribute to the good of the collective enterprise. Unfortunately, there is a high correlation among the most common behaviors that are used to define an unhealthy lifestyle: smoking, drinking, overweight, and sedentary. Rather than asking people to take action to address each of these problems independently, allowing people to choose the issue that they would like to address first demonstrates sympathy and solidarity with their efforts to overcome hardships. The measure also promotes the exercise of autonomy, which has also been linked with better health.

The third standard is setting limits on the range of behaviors that should be considered for inclusion as unhealthy. Members should not be required to change behaviors such as sexual behaviors, childbearing, sexual orientation, and participation in sporting activities that elevate risk of injury because the harm of proscribing them would far outweigh the benefits to be gained by their reduction or elimination.

Each of these standards needs further specification, so the final recommendation is to leave these details to be resolved through a procedural process, such as Daniels and Sabin's (1997) accountability for reasonableness. Insurance companies should be required to present a public rationale for meeting these standards, an accounting of the anticipated benefits, and an appeals process for exempting individual cases, with a public review and rating process.

As the contentious debates about health care reform at the state and national levels in the US have shown, a significant proportion of the American public demands that individuals be held accountable for the behaviors. They do not accept the strong egalitarian position that people are entitled to an equal share of the benefits irrespective of level of effort. With conscientious development, policies can be written that achieve an acceptable balance of principles that are fair to all involved. As various plans are enacted, it will be critical to examine the effects of such policies and how much good they actually accomplish.

Article: Should People with Unhealthy Lifestyles Pay Higher Health Insurance Premiums (Part 3)

Article- Part 3 (continued from previous post)

By: David R. Buchanan

The fact that covering the higher medical expenses of people with unhealthy lifestyles on an annual basis means that others in the same plan will have to forego other possible plan benefits (e.g., eye care, dental care; or higher pay raises) is the nagging rub that points to the larger issue of honoring a social contract based on mutual obligation and mutual responsibility. There is a general sense that, if everyone did not smoke, maintained a healthy weight, drank only in moderation, and got some regular exercise, plans would cost less and/or be able to pay for procedures that they cannot now afford. Is there an ethically acceptable means to achieve the goal of assuring that all members of a collective cooperative scheme are making a comparable, honest effort at doing that which is within their power to use limited resources prudently? What sorts of ethical considerations weigh against using financial incentives to remind people to be mindful of their obligations to one another?

Dubois identifies several important ethical concerns. The most significant is that charging people more will fall disproportionately on those who already have less. Without careful crafting, charging higher premiums may further stigmatize those who are more likely to feel bad about themselves already, and it may act as a further disincentive to obtaining medical insurance, thus, exacerbating existing health disparities. As Dubois notes, its implementation may also harm third parties such as dependent children; due to the inherent opportunity costs, paying for a child's braces, for example, may no longer be affordable in families of less financial means. Finally, Dubois points out that monitoring and enforcing compliance in such schemes will inevitably prove costly. (Again, by analogy, both divorce settlements and car accidents reports have moved towards no-fault claims, due to the high costs involved in seeking to assign or apportion blame.) He raises a couple of other issues that seem less compelling. Is it a form of state coercion? It depends. Whereas it is easy to imagine horribly intrusive requirements, it is equally possible to identify terms that may not be particularly bothersome. Is it a violation of an existing social contract or an infringement on a right to health care? There are a range of existing remedies that lessen the magnitude of these concerns (such as switching insurance plans or voting in the opposing political party).

For my purposes, an interesting point raised by Dubois is the ambiguous effect of such plans on the issue of social solidarity. Schmidt (2008) describes how German law pertaining to health insurance avers an inextricable link between personal responsibility and social solidarity. The relevant section of the act, titled "Solidarity and Personal Responsibility," reads,

In the spirit of a mutually supportive community [Solidargemeinschaft], the task of the statutory health insurance is to maintain, restore or improve health of the insured. The insured have co-responsibility for their health; through a health conscious way of living, taking part in appropriately timed preventative measures [and] playing an active role in treatment and rehabilitation, they should contribute to avoiding illness and disability and overcoming the respective consequences. (p. 200)

Here, the act of actively taking care of one's health is seen to be an expression of one's participation in contributing to a collective common good. Such schemes incentivize and reward those who behave in ways that benefit the collectivity as a whole. Conversely, however, these same plans can be seen to undermine social solidarity because such meritocratic elements may be viewed as primarily benefiting those who are already advantaged and by eroding traditional notions of giving without expectation of return. In short, the issue is whether plans can be devised that benefit the least well off and reinforce the sense of social solidarity.

Article: Should People with Unhealthy Lifestyles Pay Higher Health Insurance Premiums? (Part 2)

Article- Part 2:

David R. Buchanan

Dubois reviews three ethical grounds that have been used to justify charging unhealthy people more or charging healthy persons less. (Economists consider the respective approaches fungible, that is, equivalent and interchangeable, from a rational economic perspective.) The first is based on the principle of beneficence: Encouraging healthy behaviors reduces suffering, prevents social exclusion, promotes autonomy, and reduces the threat to social solidarity (in light of potential concerns about the "free-rider" problem, where someone is seen to benefit from a system without contributing a fair share). Dubois notes that this line of justification suffers from the familiar problems of paternalism, wherein the state/government or some third party (the insurance company) asserts that it knows what is in a person's best interests better than the person himself. Beneficence may not be sufficient to override the principle of respect for autonomy, which holds that people should decide for themselves how they want to live their lives (as long as it does not harm others, as discussed below).

Dubois devotes an entire section to challenging the claim of actuarial fairness, i.e., because it costs more to treat people who smoke, are overweight, are sedentary, and drink too much, it seems only fair that they should pay more for their coverage. Dubois argues that this position is empirically disputable, and if applied consistently, would raise thorny issues about similar issues, like genetic disorders, which most people would find ethically unacceptable (e.g., should a family with a child born with cerebral palsy be charged more, following the same logic of actuarial fairness?). In the US context, the question of actuarial fairness raises three points that deserve further discussion. First, there is an important distinction to be made between public and private insurance schemes. In a competitive market system, private insurance companies can offer differential plans, and in principle, potential buyers can decide whether they consider the contractual terms fair or not. The same is not true of government-run, single-payer plans, where the issue of discrimination against poor and minority people would be inescapable (because it is an empirically well-established fact that the health behaviors and indicators at stake are more prevalent in these groups). A variation of this concern arises with respect to the difference between employers who offer a number of insurance plan options versus those who offer only a single employer-funded plan. In the latter situation, the question of equal or differential plans should be an issue for bargaining, where the employees can decide how they want to represent their collective interests, as they deliberate about the relative weight that should be given to different ethical considerations. Finally, though there is increasingly convincing evidence that the total costs of treating people with unhealthy lifestyles over a lifetime is less than the total for healthy people (because unhealthy people die younger), it is equally clear that, on annual basis, unhealthy people use more medical services. This is relevant because, in the long-term, it would be in the financial interests of the collective insurance industry to ignore unhealthy behaviors because such behaviors would eventually save them money. However, due to relatively high turnover in employment and changes in health insurance plans in the US, individual companies cannot bank on these potential savings, and hence, they see it in their interests to promote differentiated plans to attain short-term savings. That said, the idea that charging people more can be ethically justified strictly on the basis of financial calculations appears thin, unappealing, and unconvincing to most people, as it seems to diminish the value of mutual caring and commitment to a cold cash nexus.

The third grounds that Dubois discusses as justification for charging people with unhealthy lifestyles more is founded on an implicit social contract. Dubois makes surprisingly short shrift of this approach, devoting only a single paragraph to this line of reasoning, and he casts it largely in terms of individual responsibility to make productive contributions to society or "cooperative schemes" (about which he suggests that insurance schemes may or may not qualify). Dubois quickly dismisses these grounds, asserting that such arguments would require a more comprehensive theory of justice or the good society to be tenable. It may perhaps be because he is writing from a European perspective, where Rawls (1971) may not have as much influence, but I think that it is precisely in terms of a social contract that most Americans are struggling to make sense of this issue. They argue about it in terms of a powerful tension between a sense of reciprocity and mutual obligation versus sympathy and understanding about the degree to which individual health status is beyond one's personal control. People want to believe that they can and do exercise some degree of control over their own health. At the same time, it is a rare person who is not cognizant of the fragility of the human condition and the capriciousness of being stricken by disease. Given that there will never be enough money to pay for all possible medical procedures for everyone (the US already pays 2–3 times the percentage of its gross national product for health care expenditures as other industrialized nations, with little to show for it), it is imperative to use limited resources fairly. The major challenge then is coming to terms with how much individuals should be held accountable for exercising control over various health behaviors and how much weight should be given to the social determinants of health (where poor health can be explained as the result of brute bad luck due to circumstances of birth, which a just society should strive to rectify). In addition, as Rawls reminds us, finding an appropriate balance needs to be tempered with justice considerations that give precedence to concern for those who are least well off.

Article: Should People with Unhealthy Lifestyles Pay Higher Health Insurance Premiums? (Part 1)

From The Journal of Primary Prevention

by: David R. Buchanan

This commentary sets the article by Dubois on the ethical justification for charging higher insurance premiums for people with unhealthy lifestyles in the context of US health care reform. It reviews the relevance and strength of normative concerns identified by Dubois about the acceptability of such differentiated "means-tested" plans. It identifies key issues involving whether certain health behaviors matter ethically, and if so, the grounds that would justify an obligation for people to take action. The article frames the answer in terms of the need to achieve an ethically acceptable balance between the principle of equality and principle of merit and concludes with four ethical standards to focus the terms of the debate.

Introduction

The article by Dubois that appears in this issue does an admirable job of pointing out the many ethical concerns raised by the increasingly common practice of charging different rates for health insurance premiums based on one's health behaviors (e.g., smoking) or health status indicators (e.g., BMI, blood pressure). In this commentary, I would like to set these issues in the context of health care reform in the United States in order to highlight key issues that might inform the terms of the debate about its ethical acceptability here. The central concern raised by Dubois is whether or how charging people with unhealthy lifestyles more for health insurance than people with healthy lifestyles can be ethically justified.

In the US (and other industrialized nations), there is tremendous concern about containing escalating health care costs, which consistently outpace inflation. A number of mechanisms have been implemented to try to control these perpetually rising expenditures. One means is the use of capitated health care plans such as health maintenance organizations. (In capitated plans, enrollees pay a set amount for a given year of coverage, where the provider must absorb any additional costs if the services provided exceed that amount.) Another is the growing practice of charging copayments for health care visits. Reliance on a competitive market system is praised by proponents for promoting efficiency, and therefore, cost-savings (with contentious empirical evidence; see, for example, Woolhandler et al. 2003; Aaron 2003). Denying coverage to people with existing disease conditions (e.g., cancer, AIDS) is another way for individual companies to contain costs. The article by Dubois addresses the normative issues involved in financially rewarding or penalizing members of an insurance pool for engaging or failing to engage in preventative behaviors. Underscoring the controversy, Pearson and Lieber (2009) note that the initial federal Health Insurance Portability and Accountability Act (HIPAA) mandated that all workers covered under an employer-sponsored health plan pay the same premiums regardless of health status. However, federal authorities finalized rules in July 2008 granting exceptions from HIPAA for certain wellness programs, where employers can now offer rewards or penalties of as much as 20% of the total cost of covering an employee. Is this ethically warranted?

As Dubois explains, charging more for unhealthy behaviors is a form of cost-shifting. Where capitated health care plans shift the burden of controlling costs onto the health care provider, health insurance plans prorated on the basis of health lifestyle shift a share of the costs from the insurance company to the consumer. Copayments for medical visits are another means of cost-shifting to the consumer, but they also illuminate important differences with the differentiated plans under discussion here. First, copayments are applied universally and unconditionally, in contrast to the sort of "means-tested" system of charging different rates depending on one's health behaviors or health status. Second, copayments are intended to discourage unnecessary use of medical services, where differentiated plans are intended to encourage the adoption of healthy behaviors. Requiring people to do something actively is generally considered more intrusive and more onerous than asking people to refrain from doing something. These two issues—whether everyone should be treated alike, or whether there are ethically salient characteristics that justify differential treatment, and whether there are ethical grounds for obligating people to take certain actions—lie at the core of the controversies surrounding this policy.

One option is no-fault health insurance. This has been the prevailing system until relatively recently, and it is consistent with the established medical ethos of refraining from passing judgment and treating patients irrespective of the cause of their condition. The alternative is to maintain that these behaviors matter ethically, and therefore, rates should be calibrated based on the principle of merit, charging people according to what they deserve or have earned. The ready analogy here is offering discounts to drivers with safe driving records. To anticipate, if one accepts that both positions have some validity, then the challenge becomes specifying the conditions that can achieve an ethically appropriate balance between these conflicting moral principles.

Article on Fat Grafting: Part 2

Brought to you by:

By Reporter: Vanessa Welch

MEDICAL BREAKTHROUGHS - RESEARCH SUMMARY:

BACKGROUND: According to plasticsurgery.com, fat grafting is a procedure where doctors remove a patient's own fat to re-implant it where it is needed. The fat is typically extracted from body parts like the abdomen, thighs or buttocks and injected into another area that requires "plumping," such as the face. When used as a facial filler, fat grafting can improve the creased and sunken areas of the face and add fullness to the lips and cheeks. 

FAT HELPS SOLDIERS: A team of doctors at the University of Pittsburgh School of Medicine has received $1.6 million from the Department of Defense to help wounded soldiers recover from facial injuries by using technologies based on the biology of fat tissue. "As many as 26 percent of wounded soldiers suffer some kind of facial injury, which can have a huge impact on quality of life," Dr. J. Peter Rubin, Chief of plastic surgery and Co-director at the Adipose Stem Cell Center at the University of Pittsburgh, was quoted as saying. "While we can reconstruct bony structures very well, it is the surrounding soft tissues that give people a recognizable face. This project will investigate how soft tissue grafting can more precisely restore facial form and improve the lives of our wounded soldiers." The research program involves the treatment of 20 soldiers with facial injuries. The use of fat grafting for serious facial injuries, such as those resulting from roadside bombs, is performed by using specially-designed devices and instruments for harvesting fat tissue and implanting it into regions of scarred tissue. "Fat grafting, or moving fat tissue from one part of the body to another, has been used as a cosmetic procedure for decades," Dr. Rubin said. "We are now applying this technology for reconstructive surgery to accurately restore facial form after battlefield injuries."
(SOURCE: University of Pittsburgh Press Release) 

HOW IT WORKS: Dr. Rubin first removes fat from a patient's abdomen or thighs. Then, the fat is processed. Tissue layers are separated from other fluids. Dr. Rubin then re-injects the concentrated fat into the injured area. This adds volume and smoothes it out. 

STEM CELLS: THE FUTURE OF FAT GRAFTING? The research team would ultimately like to know if adult stem cells, which are present in fat tissue, will prevent grafted fat from being reabsorbed by the body. Dr. Rubin's team has separated stem cells from other fat tissue in lab studies. Their goal is to eventually re-inject stem cell enriched tissue for even better results. European studies have shown fat grafts performed with tissue enriched by stem cells shows promise. However, no studies in the United States have proven its effectiveness.

Article on Fat Grafting: Part 1

 Brought to you by: 

By Reporter: Vanessa Welch

Jeremy Feldbusch was just 23 -- and deployed in Northern Iraq -- when his unit came under attack.

"A piece of shrapnel about an inch by an inch and a quarter thick penetrated the side of my right eye. That was the start of a different battle for me," said Jeremy Feldbusch. 

The attack left him blind, brain injured, and severely scarred. Doctor Peter Rubin is part of a University of Pittsburgh medical center team, researching new ways to precisely reshape injured faces using a patient's own store of fat. 

"That's our best replacement tissue after trauma or cancer therapy," said J. Peter Rubin, M.D., Chief of Plastic Surgery at Adipose Stem Cell Center.

Rubin removes fat from a patient's abdomen or thighs. Then, it's processed -- separating tissue layers from other fluids. He then re-injects the concentrated fat into the injured area -- adding volume and smoothing it out. One potential side effect? Grafted fat may be re-absorbed by the body. Ultimately, researchers want to know if adult stem cells -- present in fat tissue -- will prevent that. 

"We know that they will be stressed by the surgical procedure, and under the stress, they are capable of releasing different growth factors that can assist in the healing process." 

For now, patients like Jeremy Feldbusch are reaping the benefits of the research-even without super-charged fat tissue. Jeremy's sunken forehead-and large facial scar- are less noticeable.