By all accounts, the coming flu season is going to be a doozy unless we all get our H1N1 vaccination soon. There's always the plain old cold too of course. I can never remember whether we are supposed to starve a cold and feed a fever or the other way around, but new findings suggest that regardless of the symptoms, respiratory viruses can be kept at bay by drinking wine.

It's not as far-fetched as it sounds. A few years ago, researchers in Spain looked into the question of how wine drinking habits relate to the risk of colds. Their subjects were 4000 faculty members of five universities across the country, who were tracked during cold & flu season for the number and severity of illnesses. When the data was cross-referenced to drinking patterns, they found that consumers of at least 2 glasses of wine a day were only half as likely to contract a viral illness as nondrinkers, and the correlation was stronger for red wine drinkers than for white. What's more, the duration of illness was shorter for those who did contract a cold or flu.

There are a couple of explanations for this. One of course is that wine drinkers may have other healthy habits that put them at less risk (researchers call these "confounding variables") but well designed studies such as the Spanish one take these into account. A more interesting possibility is that compounds in red wine have a direct effect on cold and influenza viruses, and there is good evidence to support that. One red wine compound called quercetin was tested against flu viruses and found to be more potent than oseltamivir (Tamiflu^®), at least in the laboratory. It appears that the effect is quite specific, by interfering with viral replication. A more familiar wine extract, resveratrol, has also been fairly well tested against cold and flu viruses and found to be effective (again in a laboratory setting.)

What hasn't been demonstrated is whether these compounds have any effect in supplement form. Resveratrol in particular is better-absorbed from wine in the mouth than pill form in the stomach. So my advice is wash your hands frequently, stay home if you are ill, and by all means have a glass or two of red wine with dinner.

And look for my book Age Gets Better with Wine in bookstores soon.

You might think that because of awareness campaigns and earnest research on the causes and treatment of breast cancer, women would have a good sense of what their options are these days. To be sure, it’s not a happy thing to dwell on, and anyone hearing the word “cancer” from their doctor for the first time has a hard time hearing anything else, but it still surprises me that the reconstruction option isn’t brought up often enough when mastectomy is being considered. Recent statistics from the American Society of Plastic Surgeons reveal that as many as 70 percent of women are not being offered information about their reconstructive options at the time of their diagnosis. Yet at the same time, statistics also show that more women are choosing mastectomy.

This latter point may be easier to understand, even if it seems drastic at first glance. For years, there was a big push to “breast conserving therapy” which consisted of “lumpectomy” (surgical removal of the tumor) and radiation treatment. Surgeons recommending mastectomy were considered unenlightened. But radiation is not exactly a fun experience, consisting of weeks of visits and significant side-effects for some. What’s more, the result is not always a soft, natural breast but sometimes a hardened, contracted one. Additionally, advances in genetic testing enable better prediction of who is at risk for developing cancer in the opposite breast, so some women decide it’s better to just take them both off and be done.

Of course, the decision for reconstruction is a personal one, but studies over the years reveal that it contributes in measurable ways to recovery from cancer and overall well-being. In any case, making an informed decision about it requires that one knows what the options are. The controversy about breast implants has largely died down in the wake of numerous large studies confirming their safety and subsequent FDA approval of silicone gel implants. Some women may do well with reconstruction using their own tissue, though these procedures are much bigger operations with longer recovery times. Regardless of the decision, breast reconstruction is a federally mandated insurance benefit, underscoring the importance of the reconstruction option in a woman’s recovery.

Patients often spend enormous efforts to find the right surgeon, but may give little thought to where the surgery is to be done. 

Complications can occur for a variety of reasons, and whenever there is a high-profile disaster, such as the death of rapper Kanye West's mother Donda last year, legislators and regulators clamor to show that they are on top of the situation.

Several states have passed laws requiring licensure of ambulatory surgery centers, my state of Washington being among the most recent to do so. California has been trying to enact a requirement that all plastic surgery patients undergo a physical exam prior to surgery, in view of the fact that Donda West apparently had a heart condition that should have been given consideration as to whether and where to have her surgery.

But plastic surgeons have been placing safety front and center for years. More than a decade ago the American Society of Plastic Surgeons (ASPS) passed a requirement that all office-based surgery facilities used by its members be fully accredited. These accreditations are independent and of course mandate that patients undergo an appropriate pre-operative workup, including a physical exam. Full safety training and equipment are needed to maintain good standing as well.

With the world of cosmetic medicine and surgery expanding, not everyone doing facelifts and liposuction is a plastic surgeon, and so not subject to ASPS guidelines.

So the smart consumer should be armed with several questions, first of which is whether or not the surgical facility is independently accredited. Second, the doctor should have hospital privileges to do the specific procedure being planned; this means that an outside committee has reviewed their training and qualifications. And third, don't conceal anything in your health history from your plastic surgeon.

Surgery and anesthesia are safer than ever, but only if everyone is playing by the rules.

People are more open about having "a little work done" than they used to be, no doubt about it. But there are still those who feel the need to share only with friends and co-workers on their own terms and not have it broadcasted through the gossip grapevine. Unfortunately, you can't always count on others to be discreet and respect your privacy. So is there a middle ground?

You will be helped by choosing a plastic surgeon who emphasizes a natural look. There are specific techniques that can be employed to this end, such as emphasizing volume correction more than pulling, and more of a "vertical vector" with facelifting. But there are always trade-offs: If the result is too subtle, it may not be worth it, but no one wants the overdone look either. You should return from your "vacation" appearing rested and refreshed, not stretched and spackled.

Here's my advice: First, you need a good cover story. This shouldn't be an outright lie, but if the story includes some spa services then right away there is something to explain the rested appearance. Second, like a good stage magician, you need a diversionary tactic. For women, a change of hair color and style works magnificently for this. Amazing how a new hairdo can improve one's appearance! New makeup helps too, which you may want anyway if you need to conceal some residual bruising. And for those who know your leave was "medical" and feel the need to pry, there is always the benign explanation of some "female surgery" which is technically correct for anyone with two X chromosomes, regardless of the actual procedure. Sure, it's a stretch, and I don't suggest that you use it routinely, but it's there just in case.

Fortunately, aesthetic procedures are getting less invasive and more sophisticated, yielding faster recovery and more natural appearing results. There are still no shortcuts however, so the smart consumer is an educated consumer. And more people than ever take a positive view of plastic surgery.

Sometimes smart people make choices they come to regret. That is the case with a patient I have been treating for about the past year and a half, after she received injections of what she was told was Restylane by an esthetician at a local beauty salon. She ended up so disfigured that she has already had to have surgery, and will probably need another operation. In the course of her treatment, we learned that it wasn't actually the wrinkle filler Restylane (which is a very safe and popular product), but some sort of material illegally imported from Asia. Even after laboratory analysis, we still aren't sure what it is. More importantly, the person doing the injections wasn't a licensed medical professional of any sort. Since Restylane (as with anything intended for injection) is a prescription product, it requires a medical license for purchase and use. After a long investigation, federal agents made an arrest this week for practicing medicine without a license, and other charges.

How do things like this happen? I think there are several reasons. One is that the increasing popularity of injectables like Botox and Restylane makes it seem more routine and less "medical." Because they are so safe and predictable, it may not seem as important to really do your homework and check out the provider's credentials. Slick marketing campaigns probably contribute to this perception. The particular salon where my patient had been treated is in a fashionable suburban area, so the business had a façade of being established and upscale. In this context, it just doesn't occur to most people that unlicensed practitioners would be smuggling in counterfeit products and doing medical procedures they were not qualified to do. 

So what is an intelligent consumer to do? It may seem difficult at first glance to tell the medispa on the corner offering laser treatments and wrinkle fillers from the salon with bogus Botox, but there are a few simple checklist items that help. First, although nurses and other medical professionals such as Physician Assistants can be very well qualified to do these procedures, there needs to be a supervising physician of record. If you don't see the doctor's name on the door or the printed materials you are given, that should raise a cautionary flag. Some are of the opinion that these procedures should only be done in a doctor's office, though I see this as impractical and no guarantee of better safety or results. In my view it is more important that the supervising doctor be a specialist in cosmetic medicine; some states even require that medispa owners be a dermatologist or plastic surgeon. In any case, no one should be offended if you ask about the doctor's qualifications.

Read more about what to seek out in Healthy Aging's online feature this week.

It reminded me of a Steve Martin gag when he was hosting Saturday Night Live. (I know I am dating myself with that reference!) His opening monologue went something like this: "Now, I don't recommend using drugs or anything like that, but I discovered these pills that will really blow your mind: placebos, man. You gotta try them." The interesting thing is, the placebo effect is real and for some, they really will get high from a sugar pill if they believe they will.

Because of this, clinical trials for new drugs and medical devices typically include a requirement to be "double blind" and randomized. Double blind means that neither the prescribing doctor knows which subjects are getting the test drug and which the inert placebo, and the randomization is a process analogous to flipping a coin for each subject enrolled. This is important in order to eliminate bias, so results cannot be influenced, but it is also necessary because some of the people in the placebo group will still get better. Only by determining whether a significantly higher percentage of the ones on the active treatment were helped can it be said that the drug was effective.

That is why testimonials and what researchers call anecdotal reports are scientifically meaningless. Regardless of how dramatic the individual story, it implies nothing about the effectiveness of the drug or supplement without objective data. But what does it say about the mind-body connection, that for some the expectation of a result is enough to achieve the result?

We do have some evidence of how it works from a study on the use of levodopa, a natural brain transmitter that is deficient in Parkinson's disease patients. This particular study found an unexpectedly high percentage of responders in the placebo group, which they determined was due to an uptick in production of the substance in the brain naturally. Talk about mind over matter! On the other hand, if you don't mind spending good money on unproven therapies, then maybe it doesn't matter.

Let's face it, surgery is scary for most people, and "going under the knife" is a proposition most sensible folks would decline if a suitable alternative exists. Anesthesia adds to the scare factor, even more than the surgery itself for some, even though the riskiest part of the day of surgery is probably the drive to the surgery center. So efforts to develop quick, minimally invasive procedures with shortened recovery times are gaining momentum. Phrases like "lunchtime lipo" and ‘weekend facelift" invoke promises of pain-free, zero-downtime recovery.

One plastic surgeon in Texas has even trademarked the term "24-Hour Recovery^TM & Out to Dinner Breast Augmentation^TM." Patients are advised that return to normal activity after a day is to be expected. As a marketing ploy it is no doubt effective but it doesn't seem to have gone mainstream as far as I can tell.

Facelifting has been accelerating too. Time was that patients were told to plan on hiding out for several weeks and come up with a good cover story to explain their absence and refreshed look. Now it seems that it can be done in an hour with hardly a pause to catch one's breath. According to the website for the Quicklift^TM, it is "often called the ‘weekend facelift' because some people have the procedure performed on a Friday, return to the office on Saturday for a quick follow-up appointment, and return to work on Monday or Tuesday. Although this may be true for some patients depending on their occupations - the downtime associated with the Quicklift will vary from patient to patient." (There is always the disclaimer isn't there?) Another one called the Lifestyle Lift® recently settled with the attorney general for the state of New York over filing false testimonials about the procedure on internet sites.

There is no question that spending less time on the operating table usually translates to a faster recovery, but when I mention the idea of doing a facelift-type procedure under local anesthesia, a key to getting these procedures done quickly, most of my patients say "no thanks." Nevertheless, improved techniques have dramatically shortened recovery time for facelifting, brand name or not.

And with the magic of lasers, liposuction is now able to remove gallons of fat faster than a speeding bullet, with recovery in a single bound of only a day, or at least so we are led to believe.  One chain of liposuction clinics (a novel concept in itself) promised a patient who subsequently saw me that they could remove 11 liters-about 20 pounds or so-in a single session under local anesthesia and she would be able to return to work in a day. Don't even get me started on that one; the American Society of Plastic Surgeons has long held (for good reasons) that 5 liters is the sensible safety limit for an outpatient.

Maybe it's our fast food society, maybe it's just overheated competition, maybe there's actually something to all this. But whether you go for the quick fix or not, don't rush the time it takes to make an informed decision.

As health insurance becomes increasingly expensive and difficult to obtain, Americans are following the outsourcing trend and going overseas in growing numbers for medical procedures. For years, America was the destination for royalty and the well-to-do in search of the most advanced technology and the best doctors, but the tide has shifted. According to a 2008 study by Deloitte, some 750,000 patients from the U.S. went elsewhere for medical procedures. While a large part of this was for private-pay cosmetic surgery, the bulk of it was for medically necessary procedures that were not affordable at home. The trend is predicted to continue, with a doubling of medical tourists by 2010 and a dollar value approaching $100 billion. Many U.S. healthcare institutions-including luminaries such as the Cleveland Clinic, Harvard, and the Memorial Sloan-Kettering Cancer Center-are getting in on the game by entering into partnerships with facilities in countries from India to Costa Rica. There are even tour operators who set everything up including the surgery and sightseeing.

It is no surprise that cost is the main consideration for the decision to travel, with total cost savings approaching 50% including travel expenses for some operations. Other drivers of this phenomenon are waiting periods or exclusions from coverage. Sometimes procedures are available elsewhere years before they clear the hurdle of FDA approval in the U.S. But whether you are headed to Rio for a rhinoplasty or Hungary for a hip replacement, there are important considerations. Certainly, there are very well-trained physicians and surgeons throughout the world, but it can be difficult to verify what the doctor's credentials are and how they compare to standards such as certification by a U.S. medical specialty board. There are other criteria for accreditation of the facility where the procedure will be done.

But the doctor and the surgery facility are only part of the package. Will language be a barrier? How will complications be handled? What are the arrangements for ongoing care back home? How will the transfer of medical records be handled? How safe is it to travel long distances soon after surgery? And what are the legal recourses in the event of medical negligence? Responsible tour operators will welcome questions such as these and have good answers.

Some see little choice, others envision a medical experience akin to the last call they made for computer tech support. Either way, it's probably here to stay.

Former Estee Lauder chairman Leonard Lauder is credited with coining the phrase “lipstick effect” to describe the seeming paradoxical rise in lipstick sales during the great depression of the 1930s. This has reportedly held true for every economic downturn since, with makeup sales rising as the stock market falls. The explanation for this is that women turn to more affordable small luxuries such as lipstick in lieu of more expensive indulgences. Apparently, putting on a good face really does lift one’s spirits, and the opposite probably holds too.

In recent years, Botox and other injectable products have become beauty essentials for many. So perhaps it shouldn’t be any great surprise that sales of these products remained steady and in some cases increased even as the market fell last year. Is Botox the new lipstick? (Credit goes to Collette Courtion, CEO of Calidora Skin Clinics for first asking the question.) All signs indicate that women are indeed turning more to Botox and nonsurgical treatments for beauty maintenance while postponing cosmetic surgery.

An interesting further wrinkle in the Botox story comes from a study published in the Journal of Cosmetic Dermatology in March. A group of doctors in Cardiff, Wales (in the U.K.) evaluated the specific effects of Botox on mood. Since Botox works by relaxing hyperactive muscles of expression, they wondered whether this might have any feedback effect by elevating mood. They point out that facial muscles don’t just express emotions, the act of expressing emotion is part of the way that feelings are experienced. In particular, the muscles that cause the furrows between the eyebrows are involved in a range of feelings, from anger to worry to stress. So they used a standardized test of mood called the Irritability-Anxiety-Depression Scale, and found that after Botox treatment to those muscles people did have a measurable improvement in mood and sense of well-being.

Of course lipstick may provide the same type of benefit, but with Botox there seems to be more going on than simply “if you look good, you feel good.” Emotions are complicated things but there is no question that a positive outlook is helpful. So maybe Botox isn’t just the new lipstick, but something like the new Prozac!

I recently became aware of a new type of product called “vitamin enhanced water beverages.” There are quite a few of them too, and they all seem to make a pitch about how healthful they are, being laced with antioxidants and vitamins. Implicit in the concept is that water is improved by adding these nutrients. But it makes me wonder: Isn’t water already a healthy beverage?

It doesn’t take much effort to see that these “enhanced” versions of H₂O are actually sugary pop in disguise. Just look at the ingredients list and you will notice that the second ingredient (meaning the second highest amount) is always sugar. I’ve made it even easier for you by tabulating the ingredients myself, from all of the brands on sale at my local supermarket. In no particular order:

Snapple® antioxidant water: “Purified water, sugar …”

Sobe® lifewater: “”Filtered water, sugar …”

Glacéau vitamin water: “Reverse osmosis water [read: water], fructose (natural sweetener) …” (Natural or not, sucrose is sugar.)

Talking Rain ActivWater™: “Water, organic cane sugar …” This one boosts its antioxidants with tea extract, begging the question: Why not just have tea?

Propel®: “Water, high-fructose corn syrup …” Starting to see a pattern here …

So what about the vitamins and antioxidants? Firstly, it is highly doubtful that the extra vitamins are doing any good. Despite the common perception that they fight off colds, boost the immune system, and are generally magic in myriad ways, every major study of vitamin supplementation has failed to find a measurable benefit, and the consensus among experts is that they probably do more harm than good.[1] So while there are some instances (such as vitamin D) where a case can be made for extra dosing, the view that “enhancing” your liquid refreshment with vitamins doesn’t hold water.

The addition of botanical antioxidants (acai, pomegranate, blueberry) makes more sense. As a rule, they are much more potent as dietary antioxidants than vitamins. But here’s what makes more sense: drink regular water, and spend your money on acai or pomegranate juice or blueberries. Somewhere along the line we seem to have bought into the idea that the good nutritional aspects of healthy foods can be extracted, then added to a sugary drink to make it into a healthy one. You’re smarter than that.

Otherwise sensible people often don't give a second thought to stocking up on pills from the health food store while neglecting to fill their prescriptions or take their medication as directed. Noncompliance is one of the most significant problems in medical care across a variety of specialties, particularly for conditions like high blood pressure that don't have any overt symptoms. What people assume, often erroneously, is that supplements must be safe because they are natural. Many of these are marketed as anti-aging nostrums, and the reasoning is that they can't hurt but might help, so why not? Physicians on the other hand are perceived to be biased in favor of drugs, and so patients decide to hold back information about their supplement use.

This can have deadly consequences. The stimulant ephedra (ma huang) was responsible for several deaths among prominent athletes before being banned, and those are just the ones we know about. Clearly some of these substances are powerful, and even riskier when they are being taken in combination with drugs or other supplements. What many people are unaware of is that there is almost no regulatory oversight of supplements. Prior to 1994, the FDA disallowed health claims for herbal supplements, but the passage of a law called the Dietary Supplement and Health Education Act reclassified them as foods, resulting in looser regulations. So while prescription drugs have to undergo extensive (and expensive) testing to document safety and effectiveness, herbals have no pre-marketing requirements at all. The FDA can only intervene when it becomes clear that they are harmful.

This is starting to change. Since the passage of the original law, the FDA has published guidance on reporting requirements for adverse events, and Good Manufacturing Requirements for dietary supplements. They asked the Government Accounting Office (GAO) for suggestions on improving safety with supplement use. They issued a set of recommendations in January. As these are implemented, we can expect some tightening of the claims being made and how these products are marketed, but without another act of congress, the FDA lacks the authority to do very much. So in the meantime the best policy is a skeptical mind and open communication about what you are using with your health care provider.