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).

These patients want fuller upper breast poles with breast tissue completely above the breast crease and no skin scars. Many also do not want breast implants. This is clearly not possible but a variety of options with variable tradeoffs are available. Historically breast lifts were performed by only removing excess breast skin. This was associated with a high recurrence rate as the skin and scars stretched over time. In the 1990s Brazilian surgeons began to shape the breast tissue under the skin at the time of surgery in order to decrease these recurrence rates.

When designing the pattern of skin removal one of the surgeon's goals is to leave the patient with a round areola and no stray areola skin outside the confines of that round areola. The areola can be distorted by tight suture closures after removal of the skin excess. Another goal is to increase the visible skin between breast fold and nipple visible when one is standing upright. This is particularly important in breast augmentation because only putting breast implants into someone without this skin show on standing will not result in a good appearance.

Women with drooping breasts tend to choose large bra cup sizes for comfort reasons. After breast lift surgery, without augmentation or fat grafting, they commonly choose a bra that is a cup smaller than the one they wore before surgery. Breast lifts or mastopexies are frequently performed in conjunction with other breast procedures such as reconstruction after cancer surgery, breast augmentation and breast reduction with the removal of highly variable amounts of breast tissue. To improve symmetry different approaches are often employed for each breast.


  • Crescent Mastopexy

  • Crescent Mastopexy is the removal of a crescent or half moon of skin anywhere along the edge of the areola on a portion of its circumference. The crescent can be only skin and/or can involve deeper tissues. The skin only type is mostly used to adjust nipple position at the time breast augmentation in order to improve breast symmetry. The crescent can be placed anywhere around the edge of the nipple complex so the nipple can be moved in any direction. If you place a breast implant without doing this asymmetry can be increased leading to an unhappy patient after surgery. The deeper tissue crescent removal is used to change the shape of the breast, to make a tuberous breast rounder. The deeper tissue removal can also be done with various patterns of skin removal to achieve the best result.
    crescent mastopexy
    The main limitation to the procedure is areola distortion if the skin crescent width is too large. In most cases this limit is 1cm in width.
  • Circumareolar Mastopexy

  • This procedure involves the removal of a donut of skin around the areola so it is also called a donut mastopexy or Benelli mastopexy.
    circumareolar mastopexy
    Some years ago these were done cutting out large donuts and freeing up the skin down to the breast crease and up to the collar bone. Patients liked this approach because they felt a scar around the areola would be less visible but these aggressive circumferential mastopexies were associated with multiple problems. The limitation of the procedure is the outer of the donut cannot be more than 1.5 to 2 times the circumference of the inner donut. If you exceed these dimensions the breast mound is flattened, the areola is stretched over time to abnormal size, the scar thickens and widens so it is more noticeable and the outer edge skin can bunch up creating a corrugated cardboard or pleated appearance.
    To maintain areola shape over time many surgeons place a round purse string suture in the surrounding edge of skin. This suture can pull through the tissue, break or poke through the skin losing its ability to maintain the areola shape. In case reviews this type of lift is associated with highest rate of revision surgery.
  • Vertical Mastopexy

  • Vertical mastopexy raises or lifts the nipple by removing an inverted triangle of skin between the nipple complex and the breast fold. When the triangle is closed the nipple is pushed upward.
    vertical mastopexy
    The size of the triangle is limited by the tendency of this lift to flatten the lower half of the breast with larger triangles.
  • Y-scar Vertical Mastopexy

  • If the nipple is in a good position and the majority of the excess skin is in the horizontal plane a horizontal crescent combined with a vertical ellipse removal of skin results in a Y-scar vertical mastopexy. 

y-scar vertical mastopexy
    The main use of this lift is to minimize skin surface scarring and avoid a horizontal scar in the breast fold. This lift however will not fill the upper half of the breast and the amount of skin that can be removed is very limited.
  • Circumvertical Mastopexy - Lollipop Mastopexy

  • This approach combines a circumareolar with a vertical lift.
    lollipop mastopexy
    This is used most frequently in conjunction with breast augmentation in patients who do not have visible skin between the nipple complex and breast crease when standing. The lollipop lift removes an eccentric oval of skin around the nipple complex and the vertical limb of the lollipop ends somewhere between the nipple complex and the crease or in the crease itself, depending on the amount of nipple lifting required. The excision around the nipple complex is subject to the same limitations as the circumareolar mastopexy. The nipple cannot be lifted more than about 2 cm with this approach as the breast mound begins to distort with greater lifting.
  • Inverted T Mastopexy

  • The inverted T-mastopexy has been the work horse of breast lift and breast reduction surgery for decades.
    inverted T mastopexy
    This anchor shaped skin removal pattern allows the removal of the greatest amount of skin with greatest amount of nipple lifting and gives the surgeon the greatest exposure to perform maneuvers on deeper breast tissue. The trade off is that it has the highest skin scar load of all the breast lift procedures.
    This is the indicated method for breast lift surgery after large weight loss whether it is diet or weight loss surgery related and whether or not a breast implant is placed. Massive weight loss patients have severe breast tissue drooping and a lot of excess skin. This approach allows the removal of excess skin all the way to the sides of the torso and allows the surgeon to tack the breast tissue high up on the chest wall.
    This type of lift has the highest "bottoming out" rate compared to other types of lifts. Its occurrence is minimized by making the vertical limb of the T only 5 cm. 
    There are variations of this which result in L shaped skin closures/scars.

    L mastopexy
    They fall between inverted-T and vertical designs. Some surgeons like them but I have not found them to be useful in most cases due to the asymmetric removal of skin relative to the mid-breast axis.

  • Parenchymal Fixation, Redistribution, and Autoaugmentation Techniques

  • As mentioned above the recurrence rates due to skin and scar stretching and inadequate filling of the upper half of the breasts associated with skin only procedures has lead surgeons to lifting procedures with manipulation of the breast tissue deep to the skin. These include suture fixation of the breast tissue to chest muscles, cutting into and redistributing breast tissue,
    inserting prosthetic absorbable or non-absorbable meshes to hold and shape the breast tissue,
    circumareolar mastopexy with mesh
    injecting fat from other areas of the body and creating slings of denuded skin from the excess that is otherwise removed that are sutured deep in the breast to hold and lift the tissue (laser bra lift). There have been no controlled studies that prove the superiority of these techniques over skin only procedures. Many of these originated in Brazil and I saw them when I was training there but gave them up after a short trial in the US as I felt that long term they did not do anything other than add to operating room time and the expense of the surgery. Stitches between breast tissue and chest muscle eventually pull through the fat. Tongues of breast tissue that are dissected out and passed under the breast mound can die and therefore only result in a smaller breast. Absorbable meshes dissolve and any utility they provided disappears shortly thereafter.
    Recognizing this problem with breast fat sutures some surgeons have advocated punching a hole in the muscle and passing a tongue of breast tissue from under and behind the muscle to on top of the muscle (Graf Mastopexy).
    graf mastopexy
    This is supposed to circumvent the problem of sutures pulling out of the breast tissue but introduces the possibility of breast distortion when the muscle is activated.

There are many different ways to perform a breast lift and even more minor variations of those ways. What is effective in one patient will not be so effective in another. If you see 10 different plastic surgeons you will get 10 different answers as to what type of breast lift should be performed. It is even more complicated if you place breast implants for augmentation at the same time. That is because the markings on the skin for surgery are made before the implants are placed and it can be very difficult to plan surgery accounting for skin stretch after the implants are in place. These combined procedure patients therefore have a high rate of redo or revision surgery even in the best of surgical hands.

My preferred lift procedures are crescent, circumareolar, lollipop and inverted T depending on an individual patient's needs. I have not found the others to be beneficial in my patient population.


inverted T mastopexy

45 years old, 5'2" tall, 125 lb., 38C bra size, inverted T mastopexy
Note that skin is not visible between the nipple and breast fold on the standing view before surgery. Breast augmentation alone in this type of patient never ends well.

crescent mastopexy with breast augmentation
crescent mastopexy with breast augmentation

23 years old, 5'3" tall, 110 lb., 32B bra size
Smooth saline implants (400cc on the right and 375cc on the left) were placed under the muscle. In this case both nipples had to be moved closer to the midline during surgery using crescent mastopexies. Breast augmentation without a mastopexy would have increased the nipple divergence.

The aesthetic goal in breast surgery (augmentation, reduction and lift) is nipples that are 20cm from the notch on top of the breast bone, 11cm from the midline and 7cm from the fold under the breast with all of the breast tissue centered under the nipple. Sometimes we go to 21 vs. 20, 8 vs. 7 etc. to end up with less skin scarring/smaller skin incisions. No matter how much lifting we do we cannot get the kind of upper breast fullness seen in the bottom photo without a breast implant. In some cases fat grafting may achieve the desired amount of upper breast filling.

Internal Bra Breast Lift
Breast Augmentation
Breast Lift - Mastopexy

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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.

Tuesday, November 12, 2013

10 Things to Consider Before Having Plastic Surgery

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1. What is my surgeons training background?

Traditionally, doctors from just four medical specialties — plastic surgery, dermatology, otolaryngology (ear, nose and throat), and ophthalmology — have handled the bulk of cosmetic offerings, including everything from minimally invasive aesthetic treatments like botulinum toxin (sold under the brand name Botox) to more involved procedures like face-lifts. And those specialists spend years honing their chops in residency training programs that teach skills unique to each specialty in addition to basic surgical skills. Now doctors in these and other specialties may take a weekend course as the only preparation for doing your surgery. “Unfortunately, this is an industry where the most creative, assertive, sexiest marketing often drives the business, but it may not be someone with the best experience,” said David B. Sarwer, a professor of psychology at the Perelman School of Medicine at the University of Pennsylvania.

Monday, November 4, 2013

Smoking Adversely Affects Facial Aging

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The link between smoking and premature facial aging was first made in 1971. Surveys of twins attending the annual Twin Days Festival, held in Twinsburg, Ohio between 2007 and 2010 conducted by Case Western Reserve University department of Plastic Surgery have corroborated this. In each pair of twins, either one twin smoked and the other did not, or one twin smoked at least five years longer. Pairs in which neither smoked or the difference in smoking was less than 5 years were excluded.Fifty-seven of the included 79 twin pairs studied were women, and the average age was 48. The twins completed questionnaires regarding their medical and lifestyle histories specifically sunscreen use, alcohol intake, work stress and smoking history. A professional photographer took standardized, close-up photographs of each twin's face. Without knowledge of the twins' smoking history, plastic surgeons then analyzed the twins' facial features in the photos, including grading of wrinkles and age-related facial features to identify "specific components of facial aging" that were affected by smoking.

Smoking Adversely Affects Facial Aging
The sister on the left smoked 17 years longer than the one on the right which accounts for larger jowls, lip wrinkles and lower eyelid bags not present in the sister on the right as well as the deeper frown and laugh lines in the sister on the left.

The conclusion of the study was that the effects of smoking on facial aging are most apparent in the lower two-thirds of the face specifically lower eyelid bags, malar bags, upper eyelid skin excess, the lips, laugh lines and jowls.  The forehead wrinkles, frown lines and crow's feet wrinkles were not statistically different.  Smokers had more sagging of the upper eyelids, as well as more bags of the lower eyelids and under the eyes. Twins who smoked also had higher scores for facial wrinkles, including more pronounced nasolabial folds, wrinkling of the upper and lower lips and sagging jowls. I had once had a patient who smoked only holding the cigarette on the right side of her mouth. She had aging wrinkles of the right upper lip but not of the left upper lip. In her case one side of her face aged more than the other.

The take home message is do not smoke to lessen the need for cosmetic surgery and do not smoke afterward to maintain the results of cosmetic surgery for a longer period of time.

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Sunday, October 20, 2013

Heart - Coronary Artery Stents and Cosmetic Surgery

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Heart (coronary) artery blockage is a local blocking or narrowing in the arteries on the outer surface of the heart by accumulated deposits of plaque, which is mostly bad cholesterol. Every artery in the body is a blood pipeline. These pipelines get blocked with accumulation of bad cholesterol. When a cardiologist suspects blockage or narrowing of any of these heart arteries he/she will perform an angiography (threading a catheter up a thigh artery to the heart to inject a dye that is visible on X-ray) to view the inside of the arteries. When an area of artery narrowing or blockage is identified a catheter with a balloon is inserted along the same path and inflated at the problem area to open it up. This is called angioplasty. Increasingly stents are placed at these angioplasty sites to keep them open in the long term. In some cases multiple stents are sequentially placed in the same artery. If the area cannot be treated in such a fashion open heart surgery is required which involves opening the rib cage and bypassing the blocked area with a vein graft or connecting an artery from inside the rib cage to the downstream side of the blockage. These procedures have helped prolong the life of countless heart disease victims. This blog only addresses patients who have had stents placed. It does not address those who have had open heart surgery.


Tuesday, October 1, 2013

Blood Clots, Venous Thromboembolism, Pulmonary Embolus and Cosmetic Surgery

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In a previous blog I discussed Bleeding Disorders and Cosmetic Surgery focusing on bleeding tendencies and abnormally low blood clotting. This blog deals with the other side of the coin abnormally high blood clotting. These clots usually form in large veins of the leg or pelvis or in the chambers of diseased hearts.

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