Saturday, July 4, 2015

Body Dysmorphic Disorder - BDD and Plastic Surgery

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Body dysmorphic disorder (BDD) is a syndrome characterized by a strong preoccupation with an imagined defect in a person’s appearance. In cases where the deficit is not imagined and a slight defect is present, the person’s concern is noticeably excessive. Excessive preoccupation with the imagined or minor flaw involves intrusive thoughts about the body part of concern. In addition to daily intrusive thinking, individuals suffering from BDD engage in a variety of compulsive behaviors aimed at alleviating the anxiety caused by the thoughts. Patients with BDD generally engage in thoughts and behaviors related to their perceived deficit for 1 hour or more per day, and that amount has been reported as high as 3 hours per day among adolescents. Symptoms often start in adolescence or early adulthood brought on by remarks made by peers or family members i.e. early bullying and family attachments are significant factors. The average age of onset is 16 to17 years, although it may occur in older adults overly concerned with their aging appearance. Individuals with BDD frequently check their appearance in mirrors to confirm or attempt to conceal the perceived deformity. They may engage in long rituals of grooming, such as repeatedly combing or cutting their hair to make it just so, applying make-up, or picking at their skin. They typically will spend a great amount of time trying to cover up or camouflage the perceived defect employing elaborate clothing rituals. They will seek excessive reassurance from friends, family members, and/or co-workers to elicit placation that the perceived “defect” does in fact exist, or to assure that the flaw is sufficiently concealed. At the extreme they feel anxious around others, avoid social situations, become housebound, only leaving their homes at night to avoid the scrutiny of others. Some drop out of school, avoid job interviews, or do not work in order to avoid public exposure . Patients with BDD have attempted to engage in self-surgery with knives or razor blades to pick at or remove the blemish or with staples to tighten “loose skin". Clearly they see something that others do not see real, imagined or exaggerated.

Since the rise of smart cellphones, social media and reality television promoting narcissistic behavior the majority of BDD patients  have a compulsion to repeatedly take and post selfies on social media sites. They might take several selfies over and over again until they find the right one. Picking out details about their eyebrows, skin, noses, smiles, teeth, hair and so forth, all in an attempt to find the perfect angle to make the perfect picture. As harmless as these acts all seem, they build up over time to create great forms of self consciousness and false sense of confidence feeding on itself as an ever growing consuming obsession and compulsion. Instead of being okay with who they are no matter what, they strive to find the right picture with all the perfect details. The more likes they get on social media sites the happier they feel. Narcissism, being obsessed with receiving recognition and gratification from ones looks, vanity and in an egotistical manner, is becoming a big problem in our digital age.  A recent survey showed that 16-25 year olds spend on average 16 minutes and seven attempts to take the perfect selfie.

Danny Bowman, a British teenager, became so obsessed with capturing the perfect shot that he would spend roughly 10 hours per day taking up to 200 selfies trying to get the perfect shot. As things got more and more intense for Danny, he lost nearly 30 pounds, dropped out of school and did not leave the house for six months as he kept trying for the perfect picture. He attempted to commit suicide because he was unable to take what he felt was the perfect selfie but the attempt was thwarted by his mother.  He stated that he “was constantly in search of taking the perfect selfie and when I realized I couldn’t, I wanted to die. I lost my friends, my education, my health and almost my life.” 40% of BDD sufferers experience suicidal ideation at some point throughout the course of their illness.

Concerns with weight fall into a separate eating disorder classification. BDD can manifest as eating disorders, obsessions with exercise and fitness and addiction to plastic surgery though the Diagnostic Statistics Manual considers them separate entities for descriptive usefulness. Even the rich and famous can be affected.  Former British glamor model, Alicia Douvall, who associated with music mogul Simon Cowel and was linked to actor Mickey Rourke and Simply Red singer Mick Hucknall spent over £1m on over 300 procedures. At one point she underwent one operation a week because she was convinced that she was ugly.

Alicia Douvall had 71 operations and 260 procedures

Yet in 2013 she turned on her plastic surgeons saying they never refused her even when she brought a Barbie doll with her to illustrate what she wanted to look like.

Looking at Michael Jackson over the years as he gained then lost his nasal bridge, his wide base narrowed then collapsed  and his implant began to protrude through the tip it is obvious that he was the text book definition of BDD.

A man in his early twenties once came to see me in consultation for a rhinoplasty. His avoidance behaviors and exaggerated reactions to my physical findings were a red flag. I told him it was my policy to send males in his age group for this surgery for evaluation by a psychologist. Luckily, I had another patient who was a psychologist specializing in BDD. To my surprise a phone call corroborated the diagnosis of severe BDD with suicidal tendencies, and avoidance of socialization by not working and spending most of his time at home where he was cared for and medicated by his physician parents. I was warned not to operate on him no matter what. Another female patient was overly concerned about her facial bones and her urgency in obtaining surgery for non-existent deformities was alarming. I sent her to the same psychologist who told me that she did not have BDD which surprised me even more than the assessment of the man in his twenties. Needless to say I refused to perform surgery on both of these patients.

In light of the risks and harms cosmetic surgery can cause patients with BDD, having a systematic process for identifying such patients is imperative. A study published in January 2015 described a screening questionnaire using utilized the Body Dysmorphic Disorder questionnaire (BBDQ) and the Body Dysmorphic Disorder Structured Clinical Interview for DSM-IV (BBD SCID) in 234 patients presenting for facial plastic surgery for this purpose. They confirmed a diagnosis of BDD in 13.1% patients undergoing cosmetic surgery and in 1.8% of those undergoing reconstruction surgery. The BDDQ was determined to be 91.7% accurate, 100% sensitive and 90.3% accurate in screening patients for BDD, according to the researchers. In patients with BDD, the nose was determined to be of most concern (56%), followed by the skin (28%), hair (6%), chin (6%) and ears (6%). Those with markedly excessive concern over their noses report distress regarding its size or shape. Concerns with the skin typically involve acne, wrinkles, and spots. Thinning and balding are usually the main concerns reported among individuals preoccupied by their hair. Patients with BDD were found to have elevated depression levels compared with patients without BDD. This explains why Michael Jackson had more nose surgery than any other surgery.

 Other epidemiologic studies have shown

52% are women, 75% are Caucasian, 12% are Afro-American and 12% are Hispanic.

Three out of 4 people with BDD are unmarried; however, women with the disorder are more likely to be married and men more likely to be single.Women are frequently troubled with their overall weight and the size of their hips, waist and breasts; men are more distressed about their height, genitals, penis size and hair. Men are also more likely to exhibit a specific type of BDD, referred to as muscle dysmorphia, a preoccupation with being too skinny and lacking enough muscle that leads to anabolic steroid use. Over the last decade buttock size has been a major focus for a variety of reasons. Leading to multiple deaths and deformities (see my blog Brazilian Butt Lift).

 Areas of focus in men and women with BDD
Most patients are concerned with more than one body part at a time especially those obsessed with exercise, fitness and muscle size. In fact, the average BDD sufferer is concerned with three to four features at once.The overall prevalence of BDD in the U.S. population is 2.4%, but the incidence is significantly higher within the cosmetic surgery population. Among cosmetic surgery patients, the reported prevalence rates range from 2% to 7%, and the rates range from 9% to 15% among dermatology patients. Thus the prevalence of BDD among the overall aesthetic patient population may be up to 7 times higher than in the general population. 

Although BDD is treatable most people with BDD delay seeking help for fear of being dismissed as vain. The earlier it is diagnosed, before the thoughts and anxieties have become fully ingrained, the easier it is to treat. Treatment consists of a combination of an anti-depressant medication and cognitive behavioral therapy with a psychologist/psychiatrist before and after, or instead of a cosmetic procedure.Cognitive therapy teaches patients to identify unhelpful thought patterns and replace them with more constructive ones, control anxiety and obsessional rituals, increase self esteem and feel more comfortable in social situations. It does not focus on the cause of BDD. It can take several months for the treatment to take effect. The minimum treatment duration is 2 to 3 years and medication may need to be taken for life to prevent relapse. Psychoanalysis is time consuming, expensive and an unproven treatment for BDD. The BDD sufferer on the other hand is convinced surgical or medical treatment is necessary and psychological treatment will not resolve their problems. While delaying appropriate treatment the BDD sufferer may try to cure themselves with plastic surgery but only 10% of those who do will be happy with the result of their surgery. Hence the propensity for them to have multiple procedures. Sadly in today's world if you look hard enough, you will find someone who will do almost whatever surgery you want.  A large number of those who undergo plastic surgery experience a worsening of their BDD symptoms, while others may develop a preoccupation with another body part. Studies have consistently demonstrated that the majority of people with BDD do not benefit from cosmetic treatment.

Family members of someone with BDD should:

  • avoid debating the existence of the perceived defect because that can entrench the delusion
  • set boundaries such as being alone in bathroom time
  • avoid contributing or condoning rituals or avoidance behaviors such as making excuses to employers or providing camouflage materials
  • not supply money for cosmetic surgery because the surgery will not solve the problem
  • encourage treatment by a psychologist or psychiatrist specializing in BDD because it is highly unlikely they will initiate appropriate treatment on their own

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Tuesday, May 26, 2015

Plastic Surgery Rehabilitates Criminals

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Between 1953 and the early 1960's Dr. Edward Lewison performed free plastic surgery on inmates of the  Okalla prison in Burnaby, BC Canada. It was renamed Lower Mainland Regional Correctional Centre in 1970. The study involved 450 prisoners and was undertaken with the cooperation of Dr. Guy Richmond, the prison doctor, and Hugh Christie, the warden. Dr. Lewison and a sociologist chose patients on the basis of a  connection between a "bodily defect" and the inmate's behaviour. The idea was that reconstructive surgery that removed deformities would provide such a boost to the prisoners' self-esteem and confidence that they would be motivated to pursue law-abiding lives upon their release from prison. Most of the operations were for congenitally deformed or fractured noses. The rest were for reconstruction of deformed ears, receding chins and removal of facial scars. Almost immediately after surgery, the inmates' behavior improved. "Formerly hostile and incorrigible individuals became polite and gracious in their manner … Among them a keen ambition developed to learn a trade and qualify for transfer to the vocational correctional centre." The studies results were published in the Canadian Medical Association Journal in 1965 citing a 42 per cent recidivism rate for the plastic surgery patients vs. 75 per cent for the general inmate population. Lower Mainland Regional Correctional Centre was closed in 1991. The site is now a park.

Similar studies by different doctors carried out on inmates at Kingston Penitentiary in Kingston, Ont. in the 1960s, in Illinois starting in the 1930s and in Texas in the 1980s had similar results. The theory is still in use today by non-profit organizations in the U.S. which help reformed former gang members to remove facial and body tattoos to help get them out of gangs into jobs. I have been a I volunteer tattoo removal doctor in Los Angeles since the mid-1990s to help get people out of gangs. The patients pay for their treatments by performing volunteer community services and some have gone on to well paying executive or managerial positions. I don't think many people today would support free cosmetic surgery for inmates. In this crazy world some would commit crimes just so they could get the free surgery.
The best way to rehabilitate Two Face back to Harvey Dent would have been Plastic Surgery.

The BBC is currently looking for anyone involved to be in a documentary about the study.

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Saturday, February 7, 2015

Lipedema, Lymphedema and Fat Legs

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The 4 main causes for enlarging leg girth or circumference are lipedema (accumulation of fat in the legs), lymphedema (obstruction of lymph flow in the leg), obesity and impaired venous blood circulation (venous stasis). Lymphedema is observed as swelling that usually involves the feet and shows up as impaired flow on lymphangiograms or lymphoscintigraphy . With time the swelling becomes hard and uncompressible and the skin breaks down and becomes infected. Impaired venous circulation is observed as swelling with brown darkening of the skin color, skin break down and inflammation. The blocked veins are visualized by doppler sonography studies using sound waves transmitted through the skin. This blog will focus on lipedema also known as lipoedema in Europe.

The areas of fat concentration tend to be abdominal in aging men, hips and thighs in aging women and buttocks in certain races as those individuals age. The age at which this occurs varies from person to person. Changes in metabolism and fat deposition can also occur more quickly at puberty, after childbirth, gynecologic surgery, with the onset of thyroid disease or menopause. It is easier to lose fat from areas in which your body tends to not concentrate fat. The fat doesn't go to one place and then another as in first, second etc.. It goes all over but more of it is stored in specific areas and it is mobilized from other areas more easily. In some cases the concentration can be dramatic such as very large buttocks with skinny arms and legs, steatopygia, which is more common in certain African tribes.

Sunday, August 10, 2014

Ear Pinning - Otoplasty

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Prominent ears can be socially traumatic for children in their early school years.
It is sad that we have non-surgical ways to treat this in infants using the EarWell so they never have to go through this type of bullying yet many parents do not have their babies treated.

The surgical treatment in children or adults involves making an incision behind the ear and placing shaping sutures in the cartilage to create the missing fold that makes the ear stick out. Over the course of a month or two the cartilage reshapes itself to the shape held by the sutures so they are no longer necessary, though we do not usually go back to take them out. Depending on surgeon preference sutures are placed between the cartilage and the side of the head, skin may be removed from behind the ear and/or some ear cartilage is removed to obtain the best longest lasting ear shape.
otoplasty ear pinning

otoplasty ear pinning

otoplasty ear pinning
Before  and After Ear Pinning Otoplasty

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Friday, July 4, 2014

New Break Through Treatment for Keloids

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Keloids are the overgrowth of scar tissue in response to skin injury or irritation. They frequently persist at the site of injury, often recur after surgical removal and overgrow the boundaries of the original wound. They can itch, be painful, restrict movement, interfere with sleep, block a vital function like hearing and cause cosmetic disfigurement with significant psychological effects. The usual treatments of surgery, radiation, cryotherapy and injections can be costly and time consuming. The Division of Bioengineering, School of Chemical and Biomedical Engineering, Nanyang Technological University, in Singapore has just developed a new treatment modality that could make it easier and cheaper to treat this problem. They combined a microneedle transdermal delivery system with medications like 5-fluorouracil that have been used to treat keloids. The system consists of a flexible patch, containing microneedles 0.7 to 0.9mm in length and 1/3 mm in diameter, that is applied to the skin. The microneedles are loaded with the drug, 5-fluoro-uracil (5-FU) in a solid form. The patches are flexible so they can adjust to surface contour. The microneedles penetrate the superficial skin and swell on exposure to tissue moisture opening pores along their surface that release the drug. The release is slow and sustained rather than a sudden release of the drug. The 5-FU concentration in each patch can be varied as needed. Their price points on the product are in the range of 20 cents per patch and their goal is for patients to treat themselves replacing the patch every 12 hours without ever seeing a doctor.

Micro-needle transdermal delivery system patch

So far they have only proven the patch can be applied to pig skin, the medication is delivered over time and the product stops keloid cell proliferation in petri dishes containing such cells.. Trials in human beings have not begin so we are no way near FDA approval. We do not even know what the optimal doseage for these patches should be in different patients.The 5-FU has the potential to leave you with an open wound where the keloid once was. Therefore, I cannot see the FDA allowing a chemotherapy agent like 5-FU to be used by patients without a doctor prescription or supervision.

Scars, Keloids and Hypertrophic scars

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Thursday, May 8, 2014

Types of Breast Lift - Mastopexy

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New plastic surgery statistics released 3/31/14 by the American Society of Plastic Surgeons (ASPS) show that breast lift procedures are growing at twice the rate of breast implant surgeries. Since 2000, breast lifts have grown by 70 percent, increasing from 53,000 in 2000 to 90,000 in 2013 vs only a 37% increase in breast augmentation surgery over the same time period. Breast implants are still by far the most performed cosmetic surgery in women, but lifts are steadily gaining. In 2013, 70% of these women were between the ages of 30 and 54.

At a young age the breast skin is taut and elastic and the ligaments holding the breast tissue to the chest wall are short and tight. With aging, exposure to gravity, weight changes and pregnancy the ligaments and skin are stretched and disrupted leading eventually to drooping sagging breasts, especially after breast involution following pregnancy and breast feeding. Surgery to correct this drooping is termed a mastopexy or breast lift and involves surgery on the breast skin and/or deeper breast tissue. The pencil test is a simple way for a woman to assess if breast lift surgery could be beneficial. A pencil is placed under her breast.  If the breast tissue holds the pencil in place against the chest that implies that there’s a hanging nature to the breast that may be improved with a lift. In assessing these patients the surgeon needs to know the history of breast sizes with changes in weight or pregnancy, breast measurements (breast volume, amount of breast skin envelope filling, nipple position on the chest, distribution of breast tissue, skin quality and amount, areola size, amount of skin show below the nipple on standing and asymmetry/symmetry).

Thursday, February 27, 2014

Five Skin Care Tips for a Healthy Skin

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This is a guest post by Alyssa Furnell Content Writer/Proof Reader at Authority Specialists. Authority Specialists provides top-quality, value-filled content with the goal of building the authority of your website.

For busy individuals wanting to have their skin pampered, going for an intensive skin care is not easy. If you have a healthy lifestyle and practice good hygiene - especially in caring for your skin, then there is no need to go to a dermatology clinic. Unless of course your problem is getting rid of those hideous scars, then you really need the help of a professional, where they have a laser clinic.

Thursday, February 20, 2014

Laser Hair Removal and Hidradenitis Suppuritiva

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Lasers and Laser Hair Removal

As described in my previous blog Hidradenitis of the Armpits Hidradenitis occurs when a plug of dead skin in the duct of a gland emptying into a hair follicle initiates an infectious process as bacteria multiply within the plugged gland. As the gland swells a boil becomes visible. The obstructed gland or boil ruptures into the deep layers of the skin; adjacent glands become involved; and abscesses form. Subsequently, multiple draining sinuses or holes appear on the skin surface and the whole hair bearing area may become inflamed. Such inflammation may result in star shaped skin scars and tunneling, causing ridging of the skin. The association of Hidradenitis with hair follicles has fed the notion that removal of this hair early in the process can cure or ameliorate Hidradenitis. Since the 1990s laser treatment to remove unwanted hair has become increasingly popular therefore such treatments should to some degree treat Hidradenitis.

A laser is basically a container of some medium (such as a liquid dye, gas, etc) into which an electrical charge  or flash of light is introduced. The charge or flash excites electrons in the material at the molecular level and the material gives off a narrow band width of light as the electrons come out of excitation. The exact wavelength of light created depends on the material itself and the characteristics of the charge or flash. Mirrors inside the container bounce the light around to create a chain reaction of molecular excitation and the emitted light is allowed to escape through a pinhole. This single wavelength coherent light is then focused down into a hand piece so it can be applied to tissue. The effect on the tissues depends on which tissue components absorb the specific wavelength of light, the depth into the the tissue that the laser can penetrate, the duration of exposure to the light (pulse width), the power of the light at the point of tissue contact, etc.

Laser penetration is a factor of light wavelength with usually greater penetration for lasers with higher wavelengths of light. The wavelength also governs which tissue component will absorb a specific wavelength.

Thursday, January 16, 2014

Do It Yourself Plastic Surgery Devices and Gadgets

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As mentioned in my previous blog Plastic Surgery in South Korea South Koreans get more plastic surgery per capita than citizens of any other country in the world. In that country it is seen as a prerequisite for success in work and relationships. The patients are also getting younger so patients in their first or second year of high school are becoming common. With this high demand a number of citizens especially teens cannot afford to have the surgery so they are turning to cheaper devices and gadgets to mold their features into a desired shape or appearance. Most of these devices are designed to supposedly change facial appearance and are sold online. The sellers of these devices make claims that have no scientific basis and there are no studies proving the efficacy of any of these devices. In fact looking at some of these devices would make one think their application is more suited to a form of torture. The use or overuse of these devices could very well result in infections, permanent scars or other irreversible deformities especially in young people who are still growing.

Here is a list of available devices.

Double Fold Eyelid Glasses

Friday, December 27, 2013

Bandages and Dressings for #HidradenitisSuppuritiva

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As described in my previous blog post Hidradenitis of the Armpits - Boils Under the Armpits a plug of dead skin in the duct of a gland emptying into a hair follicle in areas of opposing skin surfaces like the armpits, under the breasts and in the groin initiates an infectious process as bacteria multiply within the plugged gland creating a skin boil. The obstructed gland or boil ruptures into the deep layers of the skin; adjacent glands become involved; and abscesses form. Subsequently, multiple draining sinuses or holes appear on the skin surface and the whole hair bearing area may become inflamed. We call this process #HidradenitisSuppuritiva (HS).

As I described my first choice of treatment for this process is surgical removal of the involved skin and closure of the resulting wound with a flap of adjacent normal skin. However, this aggressive surgery is not always the best near term option because of insurance, financial, work or personal reasons. For early stages of the disease temporizing the situation with topical treatments is appropriate and can provide significant relief.

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