Tuesday, December 18, 2007

Christmas Cleavage

What festive cleavage are you wearing this holiday season? Next to finishing up the gift shopping, I'm sure the first thing on your mind is how to dress up your breasts. At the cocktail party I attended last weekend, I was accused of a Madame X look, a reference to John Singer Sargent's infamous 1884 portrait of the American-born Paris socialite, Judith Gautreau. Her arsenic white décolleté and scandalous slipped shoulder strap drove Sargent (and the painting) out of town.

Think times have changed? Last July, when Hillary Clinton displayed even a very modest amount of chest the blogosphere went wild.

Cleavage is simply the cleft created by the partial exposure of a woman's breasts in a low-cut neckline. Or, if you're a surgeon, it's the intermammary sulcus (fun people, aren't they?). So what gives it the power to shake the world, century after century? Context, context, context. That and men are irrational over it.

Breast cleavage has been a modern, clothed phenomenon; it didn't exist in the Garden of Eden. Any tight, well-structured bodice can lift the breasts upwards and inwards (that was the wonderful in Wonderbra – as opposed to Maidenform lift and separate promise).

Prior to the advent of implants, a large busted woman's breasts merged together under pressure; cleavage became a crevice. Think Bette Midler. A really well engineered bodice can cantilever the breasts in such a way that this is minimized. Think Isaac Mizrahi observations about Scarlett Johansson's Golden Globes dress.

But when it comes to breast implants, the width of the sulcus area (cleavage) is determined by the attachments of the skin to the peri-osteal tissue covering sternum (breast bone) and by the medial attachments of the pectoralis major muscle when implants are in the sub-muscular position.

If those natural attachments are lost a host of uncorrectable deformities distort the cleavage including synmastia, the "uniboob" deformity. This can result from over aggressive dissection towards the midline, particularly in a subglandular (over the muscle) placement. Very large implants, repeated over time can have similar results. Think Pamela Anderson.

Some women have very little fatty tissue overlying the sternum so there's nothing to soften the contour transition from breasts to sternum. This causes the space between the breasts to appear wide. Since the implants must be centered behind the nipples, it's very hard to camouflage, particularly with a subglandular placement. Think Victoria Beckham. (This is something she previously denied until court papers were released in 2005 proving she had undergone augmentation surgery; it's rumored she had revision surgery prior to touring this month. Looks like it to me.)

One woman has written a tome on doing it right. Elisabeth Squires, author of Boobs: A Guide to Your Girls, thinks even older women can attractively show off cleavage, as Helen Mirren (61) does at every awards show. But beware: "If a woman of a certain age squeezes her girls together, she'll get the wrinkled, crepelike look. That's not good." Mirren's plunging bodices carefully avoid that.

Now back to the festive part. Here we have our Christmas party Goofus and Gallant example. For the office holiday party, author Squires's advice is: "[i]f cleavage isn't in your job description, don't put it in." Sorry, Britney. But the adults-only cocktail party? You've got it, Paris. Shake their world: tasteful cleavage and heels are the way to go (but put on the other stocking, puh-leeze).

Be sure and tune in FM107.1 to hear an expanded exploration of celebratory cleavage with Colleen Kruse this Thursday at 10:00am CST, subbing in for Kevyn Burger.

Want to read more about this?

Thursday, December 6, 2007

Doing Due Diligence (Certification)

ust how does one perform due diligence when selecting a cosmetic surgeon? Being an informed consumer seems more difficult than ever, given the bewildering display of high-profile disasters.

Michael Jackson, at the peak of his earning power and fame, repeatedly received very poor value for his surgical dollar. (And no, boys and girls, that's not a prosthesis; it's surgical tape on the tip of his nose.) If having more than enough money and unlimited access doesn't ensure a good outcome, what does?

The common online sentiment casts the ethical cosmetic surgeon as paternalistic gatekeeper. Most of the public expects these and all physicians to at a minimum abide by primum non nocere (not actually part of the Hippocratic Oath). It's safest to stick with caveat emptor: "let the buyer beware."

The most often hyped consumer advice is to choose a board certified surgeon. This is what Kanye West's dead mother did not do, having apparently evaluated her surgeon's credentials based an Oprah appearance.

For the prospective patient, board certification is the most readily accessible confirmation of a surgeon's training and experience. This is different than state licensure, ie, is the doctor behaving, which is confirmed here.

The vast majority of safe elective cosmetic surgery is performed by board certified plastic surgeons and otolaryngologist–head and neck surgeons. There is plenty of bad territorial ju-ju between the two specialties arising from intense competition for cash. It colors and distorts most of what is published about how-to-pick-a-surgeon. What makes these two kinds of cosmetic surgeons different from one another? There are two divergent training and certification pathways.

Here, along with the alphabet soup, is a set of cliff notes and links so you can be an informed consumer.

All physicians with M.D. after their name complete the basic 8 years post-high school education of undergraduate and medical school.

Cosmetic plastic surgeons go on to an additional 7+ years of training and certification in:
  • General Surgery Residency - 5 years
  • Plastic Surgery Residency - 2 years (some combined programs are 3 years of each)
  • ABPS board written and oral examination in Plastic Surgery
If passed, the surgeon (and about 6,600 others) now has a ABPS-recognized specialty certificate in plastic surgery and joins the member society ASPS.
  • optional Fellowship - 1 year
  • ABPS board subspecialty examination (Plastic Surgery Within the Head and Neck)
This surgeon will continue to identify him/herself as a plastic surgeon or cosmetic plastic surgeon. More societies will be joined: ASAPS. These specialty societies are the sources of the yearly continuing education of the surgeon.

Cosmetic otolaryngologist–head and neck surgeons go this direction for 5+ years:
  • General Surgery residency - 1 year
  • Otolaryngology - Head & Neck residency - 4 years
  • ABOto board written and oral examination in Otolaryngology - Head & Neck Surgery
If passed, the surgeon (and about 12,000 others) now has a ABOto-recognized specialty certificate in Otolaryngology and joins the member society AAO-HNS for continuing education in the field.
  • optional Fellowship - 1 year
  • ABOto board subspecialty examination (Plastic Surgery Within the Head and Neck) or the ABFPRS subspecialty exam
This fellowship-trained surgeon will now refer to him/herself as a facial plastic surgeon. More societies will be joined: AAFPRS. More continuing education.

The American Board of Medical Specialties (ABMS) is the major examining organization whose Member Boards (of which the ABPS and ABOto are two) certify physicians in more than 130 specialties and subspecialties. For a chart listing the current certificates offered by ABMS Member Boards, go here. (There are other, overlapping certification organizations as well.)

These board certification exams are probably the most difficult, stressful part of the not-so-young physicians training experience. The written boards are all-day specialty-specific computer-based examinations (completing the more general knowledge exams taken at the end of the first residency year). If passed, an excruciating oral examination takes place where senior physician examiners interrogate the candidate and pass judgment on the ethical and technical aspects of his/her practice.

Subspecialty certification is not required in order to practice cosmetic surgery. It's important to physicians preparing to practice because it is a recognition of exceptional expertise and experience specifically in that field.

What's important for the consumer is that board certification under the ABMS umbrella brings with it an requirement for continuing education and re-testing every 10 years. That makes these surgeons a safer bet for you and me.

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