[T212]The Arch In St Louis

Private-practice aesthetic plastic surgeon V. Leroy Young, MD, FACS, is big on conducting his own clinical research. And, thanks to that scientific interest, many of his patients aren't as big as they used to be.

Young, a senior partner at Body Aesthetic Plastic Surgery and Skincare Center in St Louis, is among a still-small cadre of aesthetic plastic surgeons who have incorporated high-volume liposuction into their practices. He did so with an unusual degree of confidence after he established?via in-house research?that high-volume liposuction is a safe and effective procedure. In so doing, he confirmed the research results of others across the country.

However, Young's investigation also uncovered a few surprises. On one hand, contrary to some claims, removing significant quantities of fat did not improve patients? resistance to insulin and did not reduce their cardiovascular risk factors. On the other hand, Young was delighted to find that high-volume liposuction induced skin to contract dramatically without the necessity of additional intervention.

?We had cautioned the participants in our study that they were going to have a lot of loose skin left over as a result of this technique and would therefore need a second procedure to address that,? he says. ?It turned out that fewer than 15% of them needed the second procedure because'to our amazement?skin contraction oc-curred naturally and did not leave the patients looking like deflated balloons.?


Thirsting for Knowledge

Young started BodyAesthetic in 2002, following his retirement from St Louis-based Washington University, where he had spent the previous 21'2 decades teaching. Two of the last residents he helped train'C. B. Boswell, MD, and Robert F. Centeno, MD?joined him as partners.

Although it has now been several years since Young was an academician, he takes great pleasure in his continuing role as a researcher. One investigatory project in which he and his BodyAesthetic partners have been participating aims to deepen current understandings of the psychological framework of patients who seek aesthetic surgery. The partners also are in the process of devising a protocol that will allow them to conduct a valid, peer-reviewable clinical trial of the controversial mesotherapy procedure.

Research projects previously undertaken by Young have delved into operating-room (OR) smoke-evacuation strategies and the physics of liposuction. Among the most important projects from earlier in his career, when he was at the university, was an immunology study that examined whether the silicone gel used in breast implants was producing auto immune diseases, as some critics and plaintiffs? attorneys had contended.

?It was an HLA [human leukocyte antigen]-typing study in which we compared women with implants to those without implants, and found no evidence of an immune reaction among women with implants,? Young recounts. ?This finding confirmed what a number of other researchers at other institutions had already determined.?

A sizable body of Young's university research dealt with the impact of breast implants on mammography and with the mechanical testing of implants.

Why does Young still engage in research as a private practitioner? ?To learn,? he replies. ?Sure, there's a benefit to the practice'it helps demonstrate that we're serious about providing the best possible quality of care. But, when you get right down to it, the primary motivation to continue engaging in research is a desire to satisfy curiosity.?


Economic Sense

The offices of BodyAesthetic are situated in leased space within a medical building owned by Washington Univer-sity-affiliated Barnes-Jewish West County Hospital, which is just across the street. Young thought that prospective patients visiting the office to discuss beauty might be put off by a traditional medical motif, so, to minimize any clinical feel, he decorated the office with trendy, upscale furnishings and allowed existing patients with a talent for painting to adorn the walls with their own artworks?not a bad customer-relations strategy.

The 3,900-square-foot office suite includes a treatment room for minor skin-care procedures and a separate area for laser work. However, every surgery that requires general anesthesia takes place at the hospital.

?We decided against building our own outpatient surgery center for the reason that it didn't make much economic sense,? Young explains. ?We've got convenient access to the hospital's accredited and top-quality operating rooms, which we pay for on a per-use basis. Had we gone the ownership route, we would in effect be paying for the surgery center even when we weren't using it.?

Along with charging BodyAesthetic a competitive fee for time spent in the OR, the hospital sweetened the pot in its bid to capture the practice's business by offering to remodel an entire floor and designate it exclusively for plastic surgery patients. ?We ended up with a very nice surgery-and-recovery environment for our pa-tients'it offers privacy and comfort, and looks out over a lake,? Young enthuses.

The consulting office likewise affords privacy, comfort, and great views, but it is also attractive because of its caring, patient-centered staff, which consists of two full-time aestheticians, four nurses (one of whom serves as a patient educator), and a research assistant.


Cohesive Team

Apart from the occasional breast-reconstruction case, BodyAesthetic is purely an aesthetic plastic surgery practice. Boswell is its face and eye expert, Centeno the rhinoplasty and bracheoplasty wizard, and Young the go-to physician for breasts and body contouring.

The surgical trio often performs procedures as a team. ?It's a little inefficient to do that because, when we're all in the operating room, none of us are in the office seeing patients,? Young confides. ?But that disadvantage is more than offset by the fact that we can offer patients a higher quality of care by having all of us in the OR together.?

The trigger for a team approach is a patient request for services that include the subspecialties of more than one surgeon. ?For example, if a patient wants work done on her eyes, breasts, and thighs, all three of us will likely be involved,? Young says. ?However, we won't conduct the consultation together; each of us sees the patient separately for that. Later, the three of us get together to discuss the procedures we're going to do and plan how the surgery will have to be sequenced.?

BodyAesthetic uses a one-for-all-and-all-for-one compensation formula for the three surgeons. ?By sharing what we earn, we've removed any inducement to compete against one another,? Young says. ?When a new patient comes in, no one tries to grab that case for himself. We can work together as true partners. It's an approach that really supports our strategy of subspecialization, and that is what allows us to make sure the patient is seen by whoever has the best set of skills to match that individual's unique needs.?


Organization Man

Outside of his practice, Young is active with the American Society of Plastic Surgeons (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS). He serves as chairman of the organizations? joint task force on emerging trends (a body charged with evaluating and validating new technologies and techniques) and as chairman of ASAPS's committee on nonsurgical procedures.

As if those responsibilities weren't enough, Young also plays an important role in managing ASPS's breast-implant registry (which he helped start), is treasurer of the Aesthetic Surgery Education and Research Foundation, and is an associate editor of the Aesthetic Surgery Journal.

?People wonder,? he says, ?why I want to be involved in so many efforts, and I tell them the reason is the same as why I engage in research. As far as I'm concerned, there is no better way to develop knowledge than through participation in a professional society. But it's also a way for me to pass along and share with my peers some of the knowledge I've been able to acquire through my own independent efforts'it?s a real thrill to be able to add to the body of knowledge about something which I'm so passionate about.?

Of his many and varied contributions through those organizations, Young be lieves that his work with the breast-im plant registry has borne the most fruit. ?The registry forced the [US] Food and Drug Administration and the manufacturers of breast implants to come to grips with the need for long-term surveillance of people with breast implants,? he says. ?There was at first a great deal of skepticism and doubt. They said the registry would prove unworkable, that people wouldn't cooperate, that it would be too costly.?

As it turned out, the naysayers were wrong. ?It is today a sustainable program with an enormous number of patients participating in it,? Young says.


Pushed From the Nest

Such matters might have concerned Young not at all had his life turned out as he originally wanted. Growing up on a farm in eastern Kentucky, Young planned to spend his adulthood raising crops?until, that is, his parents raised Cain and insisted that he go to college to enter a field other than the one adjacent to the farmhouse.

?As a little kid,? Young says, ?I always got a huge kick out of conducting chemistry experiments, so, when I went away to the University of Kentucky in Lexington, I took as many science and math courses as I could.?

Still, he wasn't sure where those courses would lead him. An aunt helpfully suggested that he become a physician. The idea appealed to Young, and he applied to the medical school at Kentucky. Later, during a general surgery rotation, he developed a love for the OR'a love that was exceeded only by the fondness he developed for plastic surgery upon exposure to the speciality during a subsequent rotation.

So enamored was he with the idea of becoming a plastic surgeon that Young soon thereafter approached the head of the plastic surgery department, Paul Weeks, MD, for guidance. Weeks was impressed by Young's eagerness, and took the student under his wing. ?Dr Weeks was a really great teacher,? Young remembers. ?He was fun to work with, and I knew that I would learn a lot from his mentoring.?

After completing his surgery internship, Young spent 2 years in the Army, and then re-turned to the university in Lexington for residency in general surgery. At about the same time, Weeks moved to St Louis to accept a position at Washington University. Young followed him there in 1979 to begin his training in plastic surgery?once again under the supervision of Weeks.

As he finished his plastic surgery residency, Young received an invitation from Weeks to join the Washington University School of Medicine faculty. Young jumped at that opportunity and served with distinction for nearly a quarter of a century. In 1999, he was appointed to endowed chair in the surgery department as the William G. Hamm Professor of Plastic Surgery .


Surpassed Expectations

Throughout his training and into the early years of his career, Young performed reconstructive plastic surgery to the nearly total exclusion of aesthetic work. He was a talented reconstructionist, everyone agreed. However, it was aesthetic plastic surgery that caught Young's imagination the most.

?Over the course of time, I transitioned from a being a hand- and upper-extremity surgeon to a purely aesthetic specialist,? he says.

About a decade after going to work at Washington, an opportunity arose for Young to transfer from the school's downtown main campus to its Barnes-Jewish Hospital satellite in the West County area of St Louis. The relaxed, park-like setting in this upscale exurban locale struck Young as being the kind of place that an aesthetic-focused practice could thrive. He eventually persuaded Weeks and other administrators to establish an aesthetic surgery office there.

The practice met and even surpassed expectations. Then, as the 21st century dawned, Weeks decided to retire, and this announcement left Young crestfallen. With Weeks out of the picture, things just never seemed the same to Young. ?The fun went out of coming to work every day,? he says.

That's when he decided to retire from academia as well and go on to start BodyAesthetic.


Business Savvy

Making the jump from a university hospital setting to a commercial practice entailed changes in approach and process that required some getting used to for Young. He and his partners were now running a purely profit-oriented business with no safety net in the form of a school bud get to catch them should things not turn out as hoped. Happily, the trio possessed abundant confidence in their enterprise?and it didn't hurt that one of them, Centeno, held an MBA degree in addition to an MD.

?Dr Centeno's knowledge of business gave us a real leg up,? Young says. ?He used his business training to put together a solid, sensible business plan for us.?

The biggest challenge Young and company faced in making a go of the new practice was acclimating the staff to the private-sector environment. ?Several of the key members of our staff had come with us from the university,? Young says. ?We had to change their thinking about how things would be done. We had to help them shed their university mentality.?

One such alteration involved choices of attire. In the past, the staff was permitted to come to work dressed in surgical scrubs and tennis shoes. That was fine for an academic setting. But Young and his partners recognized that, if their private practice were to be taken seriously as a place where creating mind-blowing beauty is Job One, the staff would have to look every bit the part.

?We instituted a dress code to address this issue,? Young says.

The staff also had to become accustomed to the idea that no arriving patient should be made to wait more than 15 minutes before seeing a coordinator, a clinician, or one of the physicians. And it became standard operating procedure to give every new and existing patient a follow-up phone call at home after a visit or procedure to ascertain whether he or she might have questions about what happened that day.

Today, 3 years later, Young isn't quite so young anymore. Even so, he still has many years ahead of him. He hasn't entertained any thoughts of hanging up his lab coat for good.

?If God blesses me with good health, I'll be at this for a long time to come,? he promises. ?I'm in no hurry to quit. I want to keep working hard at growing the practice and making patients happy.

?There remain a lot of unanswered questions about plastic surgery that I hope to be able to explore through research. There is much work yet to be done. I'm looking forward to making many more contributions.? PSP

Rich Smith is a contributing writer for Plastic Surgery Products.


Why High Volume?

Candidates for high-volume liposuction are for the most part individuals who need to be debulked before undergoing body contouring.

?We also do this in cases in which gastric-bypass patients experience nonuniform weight loss,? says V. Leroy Young, MD, FACS, senior partner at Body Aesthetic Plastic Surgery and Skincare Center in St Louis. ?For example, they lose weight in their trunk but not in their arms or legs; or they haven't lost enough weight in general to get a good result from an excisional procedure.?

According to Young, not everyone agrees on the definition of ?high volume,? ?but it's generally accepted as being anything over 5 liters of aspirate. The most we've ever done here is 37 liters. The point is, you remove a lot of fat with this procedure,? he says.

It can be done safely?that's been demonstrated time and again, he assures. However, avoiding complications interoperatively and postoperatively requires a tumescent technique that allows the patient's temperature to be properly managed during surgery, blood loss to be held to acceptable levels, and deep-vein thrombosis to be avoided.

?Because the tumescent technique is used, there's no need for special tools or ultrasound or power assist,? Young explains.

The research-oriented BodyAesthetic partners plan to begin a study soon that they hope will provide evidence that the very high doses of epinephrine used in tumescent liposuction pose no risk of serious side effects to patients.


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