Norman Leaf MD FACS

From the Blog

It's not even a legitimate debate. It's right up there with the Creationists vs. the entire body of world scientific knowledge. I don't have an issue with the folks who take the literal translation of the bible and believe that Earth was created in 6 days, since their position is pretty harmless and essentially irrelevant to my life. But the increasingly strident voice of those who choose to not vaccinate their children does have a strongly negative effect on the health of the population as a whole.

I object…

It started with a completely bogus report of a link between vaccinations and the rise of Autism, a report that was based on data that was admittedly and blatantly faked. But somehow it stuck in the minds of many, and despite all evidence to the contrary, some parents accepted it, and still take it as gospel. And celebrities, like Jenny McCarthy, put the weight of their fame behind the perpetuation of the myth. The heartbreak of a normal-appearing child suddenly developing autistic signs after a recent vaccination is frightening, but saying that the vaccination caused the problem is jumping to a really undeserved conclusion. Vaccinations and early autism do occur at about the same ages… does that mean there is a cause-and-effect relationship?

(need an example here of a superstitious thing that people do to influence the outcome of a football game)

I'm not saying that vaccinations never have negative effects…the literature is well documented on the possible reactions to them. Virtually every Western or Eastern medicine or supplement can have a negative effect if taken to excess, or if the individual is allergic to one of the ingredients. But the positive, well-documented effects of vaccinations are irrefutable…smallpox, one of the worst international plagues of the past, has killed more humans than all wars combined. Polio, the worst fear of every child when I was growing up in the 50's, is now become a vague memory. Tetanus and Whooping Cough? Highly dangerous, previously often fatal.

But what about Measles and mumps? Easy to dismiss at harmless, part of growing up…the "usual childhood diseases" as we used to abbreviate as UCD in our history and physical reports. But in fact, in certain children and adults, they can be anything but routine and harmless.

I have one personal story from my residency that I will never be able to forget. As part of my training in Plastic Surgery at the University of Chicago, I served as chief resident in Pediatric Surgery for a six-month stretch. We took care of one seven-year-old boy who decided to take a drink from a bottle of Draino, a most corrosive form of lye. As expected, it destroyed his esophagus, preventing him from even swallowing water. He had been living by means of a feeding tube leading through the skin of his abdomen directly into his stomach. Other than that, he was a normal little kid, playful and exuberant. But this was not a way for him to grow up.

We performed a difficult esophageal reconstruction, that involved swinging a part of his stomach up into his chest and connecting it to the upper part of his esophagus that was still healthy. As part of that procedure, it was necessary to remove his spleen, which was not an uncommon thing to do in several different types of abdominal surgery.

He recovered quickly, and we began feeding him very cautiously…liquids at first, then very soft foods. Soon we were able to discontinue the feeding tube, as he was getting all his nutrition the usual way…by eating. He was discharged after about two months in the hospital, and a few weeks later we received a letter from his mother with a picture of him happily eating a hamburger. It was a wonderful moment for all of us who had taken care of him. Through a very difficult recovery, he never complained.

A little more than a year later, we got word that he had died…from the mumps. The MUMPS! In retrospect, we realized that the splenectomy might have decreased his immune system enough so that this "usual childhood disease" became a deadly encephalitis.

One doesn't need to have a significantly depressed immune system in order for this to occur. The following excerpt illustrates the danger very clearly, and written much more cogently by a brilliant author. Over twenty years later, Roald Dahl wrote the following passage, aimed at parents who were refusing to give their children the measles vaccine…

Measles: a dangerous illness, by Roald Dahl

Olivia, my eldest daughter, caught measles when she was seven years old.

As the illness took its usual course I can remember reading to her often in bed and not feeling particularly alarmed about it. Then one morning, when she was well on the road to recovery, I was sitting on her bed showing her how to fashion little animals out of colored pipe-cleaners, and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn't do anything.

"Are you feeling all right?" I asked her.

"I feel all sleepy, " she said.

In an hour, she was unconscious. In twelve hours she was dead.

The measles had turned into a terrible thing called measles encephalitis and there was nothing the doctors could do to save her.

That was twenty-four years ago in 1962, but even now, if a child with measles happens to develop the same deadly reaction from measles as Olivia did, there would still be nothing the doctors could do to help her. On the other hand, there is today something that parents can do to make sure that this sort of tragedy does not happen to a child of theirs. They can insist that their child is immunized against measles. I was unable to do that for Olivia in 1962 because in those days a reliable measles vaccine had not been discovered. Today a good and safe vaccine is available to every family and all you have to do is to ask your doctor to administer it.

It is not yet generally accepted that measles can be a dangerous illness.

Believe me, it is. In my opinion parents who now refuse to have their children immunized are putting the lives of those children at risk.

In America, where measles immunization is compulsory, measles like smallpox, has been virtually wiped out.

Here in Britain, because so many parents refuse, either out of obstinacy or ignorance or fear, to allow their children to be immunized, we still have a hundred thousand cases of measles every year. [Since this was written in 1986, the success of the MMR vaccination has reduced this figure to several thousand each year, but unvaccinated children are still at risk, and some do still die of measles].

Out of those, more than 10,000 will suffer side effects of one kind or another.

At least 10,000 will develop ear or chest infections.

About 20 will die.

LET THAT SINK IN.

Every year around 20 children will die in Britain from measles.

So what about the risks that your children will run from being immunized?

They are almost non-existent. Listen to this. In a district of around 300,000 people, there will be only one child every 250 years who will develop serious side effects from measles immunization! That is about a million to one chance. I should think there would be more chance of your child choking to death on a chocolate bar than of becoming seriously ill from a measles immunization.

So what on earth are you worrying about?

It really is almost a crime to allow your child to go unimmunized.

The ideal time to have it done is at 13 months, but it is never too late. All school-children who have not yet had a measles immunization should beg their parents to arrange for them to have one as soon as possible.

Incidentally, I dedicated two of my books to Olivia, the first was James and the Giant Peach'. That was when she was still alive. The second was 'The BFG', dedicated to her memory after she had died from measles. You will see her name at the beginning of each of these books. And I know how happy she would be if only she could know that her death had helped to save a good deal of illness and death among other children.

Please understand that refusing to vaccinate your children is not simply putting them at more risk: the larger the pool of unvaccinated children, the more likely that a measles epidemic will occur. This has happened in Southern California, with the outbreak beginning in Disneyland from unvaccinated children. I am not aware of anyone dying yet from this outbreak, but there are many children whose immune systems are subpar, either from inherent immune defects, or more commonly, as a result of treatment for leukemia, other cancers, and organ transplantation. They cannot be immunized, and they have no defense against highly contagious diseases.

Not vaccinating your children is more than a harmless personal choice made under the delusion that vaccinations are harmful: it is a threat to the larger community as a whole. Please listen to your doctors' recommendations. This is not at all a conspiracy between the medical profession and the pharma industry: it's simply not a conspiracy of any type. It represents the most up-to-date research and actual factual reports from the scientific world, including the WHO, the CDC, and governmental health agencies around the world.

Teach your children whatever you believe about the creation of the world: eventually they will form their own opinions. But please! Don't jeopardize their health and the health of all children in their environment by following the words of notable quacks, uninformed blowhards and even politicians, who often condemn that which is scientifically factual, and whom, when challenged, reply, "I'm not a scientist." At least that's the truth.

We all want to do the best to insure our children have healthy, happy lives. Listen to your doctor. Immunization is as safe as any form of known medicine, and much, much safer than going without it.


The Plastic Surgeon and the Med-Spa

Over the past fifteen years, I've found that having an on-site Med-Spa and a full-time aesthetician is an essential part of my practice. In fact, I believe I was the first plastic surgeon in Beverly Hills to have a free-standing skincare clinic adjacent to my surgical office, and about fifteen years ago I combined them into one facility. The integrated surgical and cosmetic medicine concept is now widely accepted, but in the late 90's, it was a rarity.

The med-spa part incorporates a set of skilled personnel that work as a team, beginning with the aesthetician. Of course, Maya is much more than just another aesthetician…her background and training, along with her inherent intelligence, taste and hunger for learning elevates that category to a new level.

We collaborate on many levels. From a business aspect alone, her individual reputation introduces new patients to my surgical practice. When she feels that no degree of skincare or non-invasive treatments will give her client the improvement she (or he) is wishing for, it's a simple matter for her to introduce the idea of plastic surgery. In general, if she recommends a surgical consultation, a client will have enough confidence in her opinion that they will at least take that step. It doesn't always led to a surgical procedure, but at least the client will have met me, and learned the pros and cons of the procedure.

It also works the other way around…a vigorous cleansing facial a week before surgery prepares the skin for a facelift. Even more importantly, a post-operative patient can benefit enormously from her care. For example, a facelift patient does very well in the early post-op period with some gentle lymphatic massage. If they've had a laser treatment as well, a gentle cleansing and an oxygen facial around the 3rd post op day is a tremendous aid to the patient, both in appearance and comfort. Maya's personality and gentle touch is very soothing during that anxious period when a patient might be going through the "why did I do this, anyhow?" phase of recovery.

The other aspects of the medspa are essential in the current milieu of plastic surgery. I have a wonderfully skilled aesthetic RN, Joy Edwards, who offers my patients many non-invasive energy-based techniques, including the CO2 Fractionated laser, the Fraxel, the Intense Pulsed Light treatment, Ultherapy, and more. Of course, she is an expert in the latest filler and neuromodulator (Botox, et al) injections. Her patients love her work, and her practice has grown wonderfully as her patients have spread the word.

Joy and I also work together in much the same way that Maya and I do. She may do some laser or Ulthera touch-ups for a post-op patient or some filler to treat some persistent wrinkles after a facial procedure.

I also offer through the medspa a carefully collated collection of skincare products. My only requirement is that the products be both safe and effective…I am, after all, a real doctor, despite the fact that some think of Plastic Surgery as just another beauty treatment. So I apply criteria to the skincare products we dispense that are similar to those by which I prescribe medications. We carry selections from several differing manufacturers, but one of the most exciting new additions to our line is the Biologique Recherche products and treatments from Paris. If there is such a thing as The Ultimate Pre-Red Carpet Facial, this is it.

Another exciting and innovative procedure is the IV Vitamin Facial. In this unique treatment, an IV is started (painlessly), and a mixture of vitamins tailored to the individual patient is administered by an intravenous drip, while Maya performs one of her signature facials. It's a great way to rejuvenate and refresh the face and the body and spirit. Many clients will come weekly for the vitamin boost alone, especially in the winter or during times of high stress…holidays, tax time, and particularly red carpet events.

I simply can't imagine a plastic surgery practice that doesn't include these amazingly skilled professionals performing their magic on my patients. It makes my job much easier, and my patients much happier.


When I'm discussing plastic surgery with a new patient, I often find that they are more frightened of anesthesia than of the surgery itself. Everyone has heard a story about someone dying under anesthesia or waking up in the middle of an operation unable to move or talk. The tragic Joan Rivers incident has created an even greater fear (more about that later.) Very frightening tales, indeed, but despite the fact that everything in the operating room has some potential risk, the likelihood of something going quite so wrong is way overstated.

In any case, the widely quoted ratio of one death per 250,000 general anesthetics is not all that satisfying to a patient about to undergo surgery. It's like the airline industry fact that the chance of dying in a commercial plane crash is a lot less than dying in a freeway accident…a reassuring fact to some degree, but when there's a lot of turbulence during a flight, it won't stop passengers from saying their prayers.

The number is also misleading…one death per 250,000 procedures includes patients who are very frail or ill from serious diseases, and includes major heart surgery, major cancer surgery, brain surgery, and transplantation surgery. People undergoing elective cosmetic surgery are generally quite healthy…a huge difference.

I'd like to clarify a few things about anesthesia, a science and discipline absolutely necessary to a proper, safe surgery and outcome. Sadly, many surgeons have no concept of what happens on the other side of the ether screen (a term for the supporting bar that holds the surgical drapes forming a barrier between the head of the patient and the sterile operative field. The surgeon is in charge on one side, but the anesthetist rules the roost on the other side.)

During my internship at Stanford, I rotated though the Anesthesiology service for a spell, and what I learned there has helped me to understand the importance of the need for teamwork between the surgeon and the anesthesia provider, whether an
Anesthesiologist,who is an MD, or an anesthetist, who is a CRNA (Certified Registered Nurse Anesthetist).

On the face of it, most patients would say that they'd prefer having an MD taking care of such a vital aspect of their safety. In truth, most of the surgical procedures done in the United States are quite well handled by CRNA's. In the case of the most serious operations on hospitalized patients, MD Anesthesiologists generally prevail, although CRNA's are frequently part of the team. But for the day-to-day surgical procedures, especially at outpatient surgicenters, CRNA's are most commonly the choice. The most important choice for the surgeon to make is that whomever is providing the anesthesia services be well trained, experienced, capable, and can work well with the surgeon for the type of surgery planned.

Most operations I perform include local anesthetic injections, regardless of whether the patient is awake or sedated. This is done for two reasons. First, numbing the area I'm working on eliminates any perception of pain, and reduces the amount of either the intravenous medications or the general anesthetic agents (gasses) to a minimal, "keep-comfy" level, so there is a faster recovery from the anesthesia. Second, a small amount of dilute epinephrine (adrenaline) in the local solution reduces the bleeding substantially and speeds up the procedure nicely, thus reducing the anesthesia and operating time and expense.

Even with the local numbing, most operations I do are under general anesthesia…that is, the patient is totally asleep. Some patients and surprisingly, some surgeons feel that a "twilight" sleep is the safest form of anesthesia. This may hold true for brief procedures like colonoscopies, but for any procedure that takes longer than an hour or so, general anesthesia is safer. Let me explain why…

Twilight sleep, or intravenous sedation, involves medication given by an intravenous drip, usually Propofol and/or other drugs, that sedate and block out most pain and awareness. The patient will breathe on his or her own, without assistance or external control. (Propofol, by the way, despite its association with the tragic death of Michael Jackson, is extremely safe and is used in almost every modern operating room in the world. Michael's death is directly related to the ill-advised use of it without proper monitoring…just to help him sleep.)

Sounds good so far. The problem: if enough intravenous sedation ("twilight sleep") is given to make the patient comfortable and somnolent for an operation that may take more than an hour or so, the patient may not breathe deeply enough to provide enough oxygen to the heart and brain, which can lead to respiratory arrest and cardiac arrest. Unfortunately this has happened in several high-profile cases. If the patient is given less medication, he or she might be uncomfortable, and despite the lack of pain sensation, might be unable to lie quietly for a prolonged period of time without fidgeting around, which makes the operation much more difficult. But if the airway is controlled completely by a tube connected to a ventilator, (general anesthesia) one can be assured that the patient is 100% oxygenated at all times.

So, what actually happens?

After the patient is put to sleep by intravenous drugs, an airway of some type will be utilized to make sure that oxygen and some anesthetic gases are delivered to the lungs. The most common and safest airway is an endotracheal tube, a soft plastic tube about 1/2 inch in diameter, inserted into the windpipe through the mouth. A doughnut-like balloon cuff on the inserted end of the tube is then gently inflated to create a seal between the tube and the walls of the trachea. This creates a barrier to prevent any fluids from getting round the tube into the lungs, and prevents the escape of gases into the environment.

Once the airway is secured with the tube in place and connected to the anesthesia machine, it's simply not possible for a patient to have a respiratory arrest. The ventilator guarantees that the blood circulating in the body is 100% oxygenated at all times, supplying the vital organs all the oxygen they need. Various monitors are used to make certain of that, and that the heart is pumping away in a steady and rhythmic fashion, that the blood pressure is properly maintained, and that the patient's fear of waking up during surgery simply cannot occur. The tube is removed before the patient wakes up, so that its presence is not even a dim memory. These are all very sophisticated techniques and use equally sophisticated monitors, but the most sophisticated equipment is the watchful eye of the anesthesia provider himself (or herself) maintaining a close eye over the entire proceedings.

Regarding the untimely death of Joan Rivers, I don't know exactly what happened there, but I believe if she'd been given a proper general anesthesia, she'd be alive and making us all laugh today. With time, the facts will emerge. But if it was a respiratory arrest as described, which then led to the cardiac arrest and her death, I'm convinced that it just couldn't have happened with a tube in her airway. We all miss her and her naughty wit very much.


Marilyn Monroe’s Legacy, still helping our troops

The word is out…a medical chart that reveals some of Marilyn's plastic surgery (including X-Rays of her facial bones) is being put up for auction in November. And it also is becoming known that I am the owner of the chart. So I thought I'd explain the story, without the misleading distortions that I'm already seeing in the media reports.

Marilyn was never my patient…I was just entering medical school in Chicago when the news came of her tragic death. I always thought she was wonderful, and never more vulnerable and attractive than when she was playing the dumb blond singer in Billy Wilder's classic comedy, "Some Like it Hot." Her self-destructive decline after that was endless fodder for the tabloids. Hundreds of books have been written about her short and troubled life.

Early in her career, as she was being groomed for stardom, she came to Drs. Pangman and Gurdin for some minor plastic surgery procedures, a tip rhinoplasty (shaping of the tip of the nose) and a small chin implant. The chin implant was made of Bovine (cow) cartilage, a commonly used material in the days before silicone implants were available. The changes to her face were subtle ones, and her appearance was much more transformed by her hair and makeup, and perhaps most importantly, by her ability to change her facial expression at will. The gummy-smiled, curly blond-haired fresh-faced ingenue seen in her early photos could instantly become the seductress with the heavy lidded eyes, lips slightly parted in a come-hither smile, and up-tilted chin. Truly, the plastic surgery may have been the least important part of her metamorphosis.

I joined Dr Gurdin's practice in 1975, and after he retired, I became the guardian of his patient records. After a few years, it was time to clear them out. I knew of his relationship with Marilyn Monroe, and was able to find her chart amidst the tens of thousands of charts in storage. I have kept it secret and locked away for many years, not really sure what the final disposition of it should be. The idea of selling it at auction came to me after I heard that her chest xrays had been auctioned and sold for $50,000. I couldn't help feeling that the sale of a private medical record was a bit distasteful. I couldn't see selling something like that for profit only, yet the idea stayed with me.

Recently, I saw a documentary on her life, showing her entertaining the troops during the Korean War. I am the medical director of the non-profit Rebuilding America's Warriors, a foundation that provides gratis reconstructive plastic surgeries and other treatments to wounded veterans of the Iraq and Afghanistan Wars. It occurred to me that donating the proceeds from the auction of her medical records to the foundation would be yet another way that Marilyn could show her support.

And so, Julian's Auctions of Beverly Hills will be bringing Marilyn's medical record to the block in November. The chart consists of two entries: the first is from 1958, and concerns the flat appearance of her chin. The cartilage implant that had been implanted several years previously had apparently been absorbed, not an uncommon finding after that type of procedure. No treatment was recommended at that time.

The second and last notation was in June of 1962, two months before her tragic death. It describes an injury she sustained in a late-night fall. She had a small cut on her nose and a black eye. She was sent for xrays, which didn't show any fractures, although a more recent unofficial reading did show a small chip fracture which wouldn't have required surgery anyhow. Nonetheless, the facial xrays do show a view of that famous face which only a handful of people have ever seen.

The estimates for the auction are $15-30,000. But whatever the actual proceeds amount to, the funds will be put to great use in helping our wounded warriors restore their confidence and self-esteem, something Marilyn always seemed to be able to do.


Oct 01 2013

ULTHERA

ULTHERA

The Power of Sound

Sound is a form of energy. Like all forms of energy, it is a wave-based phenomenon, as is light, radiation, radio or TV. Sound can be pleasant as a beautiful symphony, irritating as a jack-hammer…or it can be something else altogether. Like a laser that focuses light into a powerful tool for tightening of the skin surface, sound can be focused to tighten tissues in and beneath the skin. The instrument that does this is called the Ulthera, a name that combines the terms Ultrasound and Therapy.

I am, as you probably know by now, not one to jump on the bandwagon of every new high-tech development being promoted by the medical-industrial complex. It took me years to begin to use lasers on my patients, because despite the enormous hype of the early CO2 lasers, all I saw were unhappy patients with faces that were red and inflamed for weeks and months, finally ending up with waxy, pasty white skin. I'm very glad I waited, because a few years ago the fractionated C02 laser was introduced. It's a fabulous tool, and I use it often, with wonderful, natural results.

So now we have Ulthera. I was, as usual, a little skeptical of the claims by the manufacturer that it actually tightened skin and underlying muscle. My skepticism was enhanced by the statement that the best results don't appear for several months. I always figured that was an excuse for something that really didn't work very well, and that by three months the patient might have forgotten how they looked before the treatment. I was wrong.

The results of Ulthera treatment (Ultherapy) can be remarkable. Part of the improvement in appearance is immediate, but, as advertised, the best results really do take about three months to appear. Before and after photos show the difference quite clearly. Jowls are tightened, looseness in the neck is improved, and the brow is repositioned subtly into a more youthful manner.

It's not for everyone. People who have a great deal of looseness will not see much of an improvement, and would be wasting time and money trying to postpone a facelift. But for younger patients, mid-30's to early 50's, (depending on the degree of sun-damage and aging), Ulthera can offer a wonderful "lift." The treatment's reputation for being painful is a bit overstated…it's quite variable and very much operator-related. With proper local anesthetic and some mild sedation and pain-killers on board, it's very easily tolerated. And there's no pain afterwards at all.

I think this is an innovation that has "legs." It will never replace a proper "invisible" facelift, but it might put it off for a couple of years or more. In any case, Ulthera will remain part of my treatment menu for years to come.