Scabs and Scab-ology 101

Scabs: A word many find a bit repulsive. Plastic surgeon’s scabs are just as repulsive as a scab from any other surgeon and mean the same thing to the patient. There are several things every patient should know about scabs and their causation, so they can be treated appropriately and heal well not affecting the ultimate scar.

First and most important, do not pick scabs. Most people find themselves wanting to pick a dry scab- a normal feeling but try to fight it. Those who cannot seem to fight the urge may have a type of mental disorder related to Obsessive-compulsive Disorder called dermatillomania. A great word for your vocabulary, if you’re into that sort of thing, simply meaning “skin picker.” I guess if you pick compulsively you’re a dermatillomaniac and should consider not having plastic surgery with skin incisions.

A scab can be considered a “blood clot” on the surface of the skin. In other words, if a blood clot was exposed to air it would look something like a scab. They have the same basic components: platelets, fibrin, serum proteins and cellular debris. They are not free-floating, they are, through their fibrin and other protein components, integral to the damaged skin they protect. That is why if you pick your now protective scab off, it will bleed and probably become an infected scab when it reconstitutes itself. There will come a time between three and fourteen days that the skin has healed beneath the scab, but it continues to hang on-barely. It is at this point when professional pickers, such as myself, may remove the scab as it has served its purpose to protect and accelerate wound healing.

The point when the scab naturally separates can be accelerated by keeping the scab surface moist with Vaseline or a Vaseline product called Aquaphor. As a rule, it is best to keep all unhealed skin wounds moist, otherwise they desiccate and are more likely to become infected and leave a visible scar.

Hair-bearing skin represents a unique problem with respect to scabs and wound healing. As plastic surgeons, we rarely shave the hair to make an incision in hair-bearing skin. Rather, we separate the hair away from the scalp incisions in a surgery like a facelift. The problem of scabbing arises when the hair gets into the wound. Our own hair is read by the body as foreign material and reacts accordingly with inflammation and scabbing. If the sutures or staples are kept moist and protected with Aquaphor, the hair is less likely to get in the wound and cause scabbing. When it does, it is best to remove the staples, make sure the hair is out of the wound, remove any scabs and keep the hair out of the healing wound with Aquaphor. I have seen cases of exorbitant scab growth from hair “contamination” of the scalp incision behind the ear. This is rare but may require re-excision of the scar.

When scabs loosen prematurely due to picking or trauma, they may become infected deep to the scab in the wound proper. The scab remains attached but exudes purulent material and is usually reasonably obvious to the clinician. The scab should be debrided into the open wound, cleaned, debrided and left un-sutured. Scheduled dressing changes, antibiotic ointment and oral antibiotics should be given. The wound usually heals within a week or two as long there are no foreign bodies inadvertently left in the wound such as subcutaneous sutures. It can be expected that this part of the incision will not heal as nicely as the rest of the wound and may need revision after six months or so.

One of the important traits of an accomplished scab-ologist is the ability to tell the difference between a scab and congealed blood on the incision and skin. Both blood clots and scabs are made of similar material except the scab emanates from a wound opening and a clot is stuck on top of the skin and should be easily removed with peroxide. Blood clots beneath the skin are the enemy as the cause inflammation and swelling putting pressure on the wound closure. If a superficial clot is spotted early, it can be expressed out the unhealed incision without sequella. Deeper clots may need to wait until the clot is liquefied at a week or so to be aspirated by a large bore needle.

After committing this article to memory, we are now all trained scab-ologists.

What You Need to Know About Stem Cells

plastic surgery dr paul howardResearchers and even medical students have known about stem cells for decades. They are the multi-potential cells in embryos that can become any cell in the body; brain, muscle, heart, etc. Years later an adult version of the stem cell was identified, not quite as basic as the embryonic stem cells, but able to become many other types of cells.

Once identified, we could grow them outside the body and stimulate them to become more advanced cells such as those composing cartilage, muscle, bone and even heart tissue.

More recently it was discovered that the bodies’ main repository of adult stem cells is in our fat (adipose) tissue. These adult stem cells can also be harvested from the bone marrow in much smaller quantities and with significantly greater pain.

This discovery was great for plastic surgeons as we are the primary surgeons who harvest fat for cosmetic reasons by suction-assisted lipectomy (liposuction). With this technique, liters of fat can be harvested at one time to be processed to release the adult adipose-derived stem cells from the fat.

There are methods that currently exist to multiply the number of stem cells from thousands to hundreds of millions, but this must be done in a laboratory and is controlled by the FDA.

These stem cells once multiplied and stimulated in the lab can become a medical treatment by replacing injured or worn out cells in the heart, joints and maybe even other organs such as the liver and kidney.

For the present, we can use a person’s own stem cells (not Aunt Thelma’s) to replace soft tissues if injured using your very own fat cells which already are charged with stem cells. Fat grafting to the face as part of a facial rejuvenation procedure has been around a decade or so in my practice. The addition of extra stem cells to the facial fat grafting we do with facelifts gives a remarkable improvement in skin tone and texture due to the rejuvenating qualities of stem cells.

The limit to stem cells is that they only work for you because you and your stem cells have the same DNA. Therefore, one can harvest and freeze your fat with your stem cells for future use but no one can “borrow” your stem cells.

Another limitation to stem cell medicine is that you cannot rub stem cells on your skin like sun block. The stem cells only work inside your body where they can interact with other cells. It naturally follows that if you cannot use Aunt Thelma’s stem cells, stem cells from other DNA sources like plants and trees have no effect on humans but are probably great for other plants and trees.

Just the words “stem cells” have become a cultural phenomenon. I’ve read recently where stem cells can reconstruct a breast and even make a small breast larger. Of course, none of that is true but fat grafting, with or without stem cells, is commonly used to reconstruct soft tissue defects of the face, breast and buttocks. The stem cells are there just to improve the amount of fat that survives with grafting and provide no volume on their own.

Advertisers who use the words “stem cells” to describe their latest, greatest fountain of youth product are taking advantage of the hyperbole of public perception which is totally different from the public facts regarding stem cells.

Aging & Fat Grafting for Facial Wrinkles

fat-grafting-for-wrinkles-and-lips

It was about ten years ago that I first met Dr. Sidney Coleman. He had just published a text called Structural Fat Grafting and was showing his results which were superior to others I had seen. I had been studying fat grafting since 1991 when I did my first case. I immediately saw the genius behind his methods backed up by beautiful photographic documentation; I purchased his book, had him sign it, bought all of the recommended equipment and was on my way.

It was about this time that it became obvious that adipose tissue was special in ways we had never figured. Our own fat turns out to be the bodies’ primary depository of mesenchymal stem cells, rather than from bone marrow, explaining adipose tissue’s ability to rejuvenate our faces when injected into the face.

After a number of years and hundreds of cases I began to notice a pattern in our results. It became clear that our older (>60 years old) patients seemed to have much less than the 80-90% graft survival that we had become accustomed to. Others had noticed the same phenomenon (PRS 2014 August; 134(z), 227-232) but placed the cut-off at 45 years of age.

Empirically we studied the gross appearance of the suctioned and centrifuged fat noticing there tended to be a demarcation within the fat layer itself. Approximately 30-50% of the fat looked somehow different, less “cellular or robust” if you will. The location of the donor fat areas also seemed to appear different with the entire specimen seeming more cellular. Donor locations have been studied and our observations confirm that flank and upper buttock fat seem more vital than abdominal or thigh fat. For younger patients the opposite seems true.

We also believe, as do others, that stem cells from older individuals seem to lose some of their “potency” in regards to being multi-potential mesenchymal cells. The rejuvenating ability of adipose derived stem cells may age and become less potent over the lifetime of the organism. This observation has practical implications as many people are choosing to donate their adipose stem cells for possible future use as a treatment for certain diseases and possibly even cancer. It makes sense to donate one’s stem cells as early- as young- as possible to have maximum effectiveness. The cryopreservation of adipose tissue is now a growing industry requiring only standard liposuction techniques to obtain the fat which is cryopreserved indefinitely for a small yearly storage fee and a one time set-up fee by the storage facility (not including in-office surgical removal).

Fanny Brice’s Nose Job

In the year 1923 Fanny Brice was the talk of the town. She was the star and main attraction of Florenz Ziegfeld’s Follies, the most attended vaudeville act of his time with the most famous attraction. Ziegfeld’s Follies was where Fanny Brice became a celebrity. Not bad for a Jewish girl who evidently suffered from image problems due to her very ethnic and large proboscis. As a comedienne on stage her nose was a perfect prop for her comic routine. At what point in her seemingly glorious life did she decide to “bob” her Jewish nose is unknown. A procedure commonly known today as rhinoplasty.

Barbra Streisand, a half century later, faced the same critical audiences that had persuaded the young Fanny Brice to change her Jewish appearance, but could not persuade Streisand to do the same. It was after Streisand’s brilliant performance in Funny Girl, a play about the life of Fanny Brice, that the questions about her looks began.

Fanny Brice was a prolific self-marketer and realized the national publicity her nose job would have. How she found her plastic surgeon, Dr. Henry Junius Schireson, a man of forty-two with a dubious past, questionable educational background as a doctor, and a reputation that he would operate on anything for money, remains a mystery.

For the event the media were notified and Fanny Brice had her nose bobbed in her hotel room by a quack surgeon. Her nose job was the medical event of the day and generated press attention until the birth of the Dionne quintuplets in Canada in 1934. Henry Schireson was an overnight sensation and probably the first celebrity plastic surgeon. It wasn’t too many years later that Schireson lost his medical license under a barrage of lawsuits and retired a disgraced man.

As far as Brice, she continued to be the gold standard for female comediennes, continued her ethnic Yiddish humor on stage until 1934 when she changed to radio and had an illustrious career on air where no one could see her new and improved nose.

Which are better: Bone Marrow or Adipose Derived Stem Cells?

In the race from body to petri dish Bone Marrow Stem Cells (BMSC) has been the standard bearer among research scientists since their discovery in the 1960’s. They have the advantage of being well-known and easily understood by researchers. The primary downside to BMSCs from the beginning has been the clinical difficulty harvesting the cells from bone marrow derived from the pelvis of the donor. This bone marrow harvesting procedure generally requires general anesthesia and is painfully difficult for the patient.

Embryonic Stem Cells, when available, were the preferred choice of many doctors until the philosophical question of the beginning of life was raised and left unanswered. The utilization of human fetuses and umbilical cords for the purpose of research has been banned in the U.S. for several years.

Adipose Stem Cells (ASC), a more recent discovery, have been shown to be easily harvested by modern techniques of liposuction with very little pain or discomfort. Liposuction is a simple office procedure without the need for general anesthesia and provides the donor with a cosmetic improvement as a secondary consequence to the attainment of large quantities of ASCs.

ASCs, besides being easy to harvest, have been shown to have 100-500 times more stem cells than an equal volume of bone marrow. When intended for immediate use, the Stromal Vascular Fraction (SVF) of the centrifuged fat contains all of the stem cells and can be used interchangeably with the isolated, cultured adipose stem cell product.

There is an increasing amount of research in the field of restorative medicine, so we are working with the Adicyte Company to harvest and make available to our patients at a future date their own adipose stem cells harvested today by liposuction. In the near future when research has become sophisticated enough to offer treatments based on autologous stem cells, your stem cells can be retrieved, thawed out and used for stem cell therapy as if they were brand new. Current therapies currently under protocol include re-growing cardiac muscle after heart attack, treating autoimmune and immunological diseases and re-growth of cartilage in damaged knees and shoulders. There is even some preliminary work in a treatment for certain cancers also.

Dr. Paul Howard now offers stem cell storage with your adipose tissue (fat) – learn more

The Wrinkle in Botox

The Wrinkle in Botox

Why you can still expect to have a Facelift

Botox Birmingham ALWikipedia’s definition for wrinkle “is a fold, ridge or crease in the skin.”   Botox is a wonderful medical break-through that has altered how some women smile, or lack thereof.  Just like many medical breakthrough products, Botox is often over-sold to the general public giving them an unrealistic expectation of results and, often, misconceptions about turning back the clock or stopping the aging process altogether.  Medical technology has yet to advance enough to alter our DNA and stop the aging process, but has given us products such as Botox that can help prevent wrinkles from occurring to some degree.

Botox is a product that paralyzes the muscles in the injected area.  Since most wrinkles are created from the stress of the underlying muscles, paralyzing those muscles helps to prevent the muscles from contracting thus it prevents skin folds from occurring.  When used prior to the appearance of wrinkles, then Botox is preventing those folds from occurring, thus the signs of aging.  When used after the signs of aging are present, then Botox assists those muscles from contracting thus relaxing the fold, or wrinkle.  Most patients can see visible improvement over time after consistent use.  However, the “wrinkle” in Botox is that is does not erase those deep wrinkles once they are formed, but can help minimize their appearance.

Deep wrinkles are the manifestations of muscle contractions over a period of time.  Wrinkles are more than just folds, they are the visible signs of soft tissue having been broken down from the stress of the muscle contracting.  A tissue replacement, such as artificial fillers or fat grafting, is often recommended to achieve the desired result of minimizing the appearance of wrinkles beyond the capabilities of Botox.

Common areas for Botox Cosmetic are the forehead, glabella (between the eyebrows), and the crow’s feet area around the eyes.  Injecting Botox to frown lines is not advisable unless you wish to paralyze your smile for about 4-6 months.  Even if you could obtain some benefit from Botox injections to the frown lines (laugh lines – or the parentheses lines that extend from our nose down to the corners of our mouth), then the manifestations of aging would still exist as gravity is a proven cosmetic disadvantage to our facial structure.  Botox injections cannot prevent gravity from pulling down the soft tissues of our cheeks contributing to those laugh lines and creating those jowls which in turn help create marionette lines from the corner of the mouth extending down the sides of the chin.

Since it is clear no one would want to Botox those frown lines, the aging process in that area will continue thus leading to a more traditional procedure such as a facelift.  Other factors that can help minimize the appearance of wrinkles are skin care, using sun-block protection, drinking plenty of water to keep the skin hydrated, and maintaining a healthy weight.  Botox is a great product for the prevention of forehead wrinkles, but one should understand it isn’t a magic potion for all areas of the face.

The Hidden Risks of Homeopathic and Herbal Supplements on Plastic Surgery by Dr. Paul Howard

The use of complimentary or alternative medicines such as those found in herbal or homeopathic preparations has increased from 20% of our patient population to more than 60% of our patients.  The fascination of herbals, teas, and homeopathic products exists because people believe these medicines to be “natural” and therefore perceived to be “safe.”  Only recently have these products been scrutinized carefully by the medical community to determine how safe they actually are.  In preparing for plastic surgery, safety issues are being addressed due to the fact that there are an increasing number of reports describing bleeding

www.paulhowardmd.com Dr Paul Howard Board Certified Plastic Surgeon Birmingham Alabama

complications due to herbal remedies.  We now know the chemistry of most herbals so we can now identify the substances within each herbal preparation that are likely to cause bleeding problems.  To date, the only documented sequelae of herbals that effects plastic surgery is the increased risk of peri-operative and post-operative bleeding which usually manifests as more swelling and bruising than one would normally see.  In more severe cases, these homeopathic medications may even cause significant bleeding and hematomas.

A partial list of common herbal supplements that are known to cause bleeding problems is provided:

Chinese Agrimony

Chinese Peony

Feverfew

Fritillaria Bulbs

Dan Shen

Devil’s Claw

Garlic

Geum Japonicum

Ginger

Ginkgo

Ginseng

Licorice

Oil of Wintergreen

Poncitrin

Red Chili Pepper

Saw Palmetto

Other dietary supplements known to effect healing or cause bleeding:

Chondroitin & Glucosamine

Fish Oil

Vitamin E

As a general rule of thumb, any herbal supplement which is known to cause or have any pharmaceutical activity should be discontinued 2 weeks prior to a general anesthetic or outpatient surgery under local or sedation.  Since many herbal or homeopathic formulations contain numerous plant extracts, it is best to stop all homeopathic remedies including herbal teas a full 2 weeks before surgery.  Patients may renew taking their supplements once uncomplicated healing has progressed for at least one week post-operatively.  It is probably in the patient’s best interest to assume all homeopathic supplements have the potential to effect healing and should be discontinued 2 weeks prior to surgery.

Dr. Paul S. Howard, Board Certified Plastic Surgeon Birmingham, Alabama

Preparing for Plastic Surgery by Dr. Paul S. Howard

Fibroblasts vs. Stem Cells by Dr. Paul Howard

The TV news media is reporting the latest “break-through” in cosmetic medicine science.  Evidently for a mere $4,000 one can take a punch biopsy of a patient’s skin, send it to a lab where fibroblasts are isolated, cultured and expanded.  This results in millions of fibroblasts which are then re-injected into the face to rejuvenate the tissues as fibroblasts are known to synthesize the protein collagen which is lost in the aging face.  This clearly is a break-through in cell biology albeit an expensive one and not a popular alternative since it doesn’t last longer than 6 months.

A different technology has been available for several years and achieves pretty much the same thing at a fraction of the cost, and it lasts forever.  Adipose derived stem cells are isolated from liposuction aspirate and then re-introduced into the areas requiring rejuvenation.  The stem cells are more basic precursor cells to fibroblasts thus are thought to transform into fibroblasts as well as other cell types that increase vascularity and provide many of the trophic growth factors that help rejuvenate skin.  Depending on their environment, stem cells can be encouraged to form cartilage, even re-create osteoblasts that form bones.  Therefore, stem cells have been used for a wide variety of clinical problems including skin rejuvenation, joint cartilage re-growth and healing, wound healing and even re-growth of cardiac muscle tissue.

All of these new technologies whether or not they are “FDA approved” need to be evaluated through the prism of overall scientific advances.  It seems that the imprimatur of the FDA allows the science to be exploited for marketing gain by the few.  Regardless, FDA involvement with these new scientific advances has not been well defined and tends to allow for marketing adulteration of the product  in question often misleading the consumer regarding other available options

Chin Augmentation

In Hollywood, where most of the talent trades on their facial attractiveness, it has been common for both men and women to enhance their profiles with chin enhancement.  Especially in men a strong jawline and profile are a must for matinee idol handsomeness.   In an industry where attractiveness is the primary currency, chin surgery has always been common; more common than anybody suspected.  So it is not a surprise that the American Society of Plastic Surgeons statistics show that chin augmentation with chin implants has risen 71% making it the fastest growing plastic surgical procedure.  Slightly more men than women are undergoing the procedure which is not a surprise due to the large cachet placed on a strong chin and jawline in men.

Implants for chin augmentation have been around for 30 years or more so the science behind the procedure is fairly well worked out.  Commonly, an incision is placed in the mouth below the front teeth on the bottom (a skin incision below the chin is also feasible).  A pocket is then created over the boney part of the chin or mentum.  This pocket is carefully placed below the tooth roots and away from the nerves that supply sensation to the lower lip.  Small improvements of 4-5 mm are easily achieved with a variety of silastic (silicone) implants with various shapes and sizes.  Most experienced surgeons would agree that a chin augmentation of 10mm or more is more difficult to obtain with an implant.  These large augmentations are associated with a small chin (microgenia) as well as a poorly defined, obtuse, neck contour.  Simply placing an implant gives minimal improvement to the neck.  Large implants are more likely to cause boney erosion of the chin due to their size and the tension required to advance the tight soft tissues.  For this reason, large chin advancements of a centimeter or more are frequently achieved with a different operation known as a genioplasty.  A genioplasty is performed again through an oral incision, but rather than placing a silastic implant, the chin bone is cut in a horizontal direction below the tooth roots so that the small chin may be advanced and fixed in position with titanium plates and screws.  If the small amount of titanium hardware becomes a problem it may be removed after healing of the bone at about 6 months post-operatively.  The intrinsic beauty of the genioplasty is that the neck muscles are left attached to the boney chin and as the chin is moved forward to effect the augmentation, the neck muscles are also tightened improving the once obtuse neck line.  In the rare instance of a chin implant infection, removing the implant and performing a genioplasty can salvage the result as the small amount of titanium used for fixation almost never causes an infection.

The most common complications of chin implant surgery are the rare infection, rare boney erosion involving tooth roots, and more commonly prolonged lip numbness (rarely permanent) with the most frequent complication being inadequate chin projection as well as over-projection of the chin giving a profile in women that it too strong and sometimes masculine.  Occasionally, a chin implant that is not properly healed can shift causing the chin to be asymmetric.  Even years after fully healing, a trauma to the chin implant can cause a secondary hematoma and inflammation necessitating implant removal.  On a very rare occasion a lower jaw (mandibular) tooth abscess can secondarily infect a chin implant, but not a genioplasty.

Over the years, many creative surgeons have tried to create chin implants with mesh material such as mersilene or prolene mesh.  The primary problem with porous materials is that they can get chronically infected causing prolonged oral drainage.  Also, these porous implants become incorporated into the chin soft tissues and thus are impossible to revise (bigger or smaller) and can be very difficult to remove.  The good news is that these so called “chin cripples” can be salvaged by a well performed genioplasty.

Chin augmentation is one of those procedures that lends itself to facial imaging.  Using the already well known proportions, the exact profile can be agreed upon pre-operatively so that no misunderstandings develop post-operatively.

All in all, chin augmentation is one of the easiest and most satisfying operations performed by plastic surgeons.  Naturally, when studying the profile, the nasal profile comes under scrutiny and in many cases rhinoplasty and chin augmentation are done simultaneously to overhaul the entire profile all at once.  Again, facial imaging can predict the profile that is desired.  One warning is in order:  Many times dental malformations (malocclusions) can mask themselves as a weak profile.  A good dental evaluation to rule out malocclusions and dental caries, especially in the lower jar, is indicated pre-operatively.  Beware the dentist/orthodontist with today’s fancy facial imaging software.  Not everyone with minor malocclusions needs $5,000 of orthodontics on a fully formed jaw.  These orthodontists many times feel the need to recommend both nasal and chin surgery acting like they and their referrals are a necessity.  This is the tail wagging the dog.  It should be very easy to identify fully trained Plastic Surgeons to perform both chin augmentation as well as the rhinoplasty in a single operation.

Call today for your consultation 205-871-3361

Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD) is a psychological disorder in which the affected person is excessively concerned about and pre-occupied with perceived defects of their face and/or body features.  The obsession with body image can be all consuming to the point where occupational and/or social functioning is impaired.  The disorder is frequently associated with anxiety disorders, social withdrawal and clinical depression.  In fact, many people suffering with BDD also have a depression diagnosis as well as obsessive compulsive disorder, social phobia, and chronic social anxiety.  BDD sufferers have a more than double rate of completed suicide and a suicide ideation rate of 80%.  Men and women are affected equally.  There is no specific cause for BDD, but is thought to be a combination of psychological, emotional, biological, and environmental factors.

Many patients with BDD are able to hide their diagnosis from plastic surgeons by down-playing the crisis within and may appear just another vain patient which all Plastic Surgeons are used to seeing.    In my experience, many of these people actually have small, but visible problems that may be described as much worse than the actual problem.  These patients usually have consulted with other Plastic Surgeons and have learned not to be too dramatic regarding the perceived defect so as to get the surgery desired.  It is only after surgery that the full extent of the problem is revealed.  Basically, these patients, if operated on, cannot be satisfied with the result even if photographic documentation shows improvement.  One way to identify these people pre-operatively is that they frequently do not see the problem in photographs, but will readily show you in the mirror or on their face.  Since these people generally spend at least an hour per day studying their visage, they can in detail describe the nature of the problem even though it may be “within normal limits.”

Many of these people describe in detail and quite convincingly how their defect has kept them from employment and socialization.  They reveal chronic low self-esteem and exhibit paranoid ideation thinking that everyone notices the problem and is secretly mocking.  They frequently will have a litany of “friends” that reinforce the severity of the problem.  If left untreated, the symptoms persist or even worsen over time.  The diagnosis is usually obvious, but can be documented with any of a number of BDD questionnaires available on-line.  Even with the chronic and unremitting nature of the disorder, it is treatable with cognitive behavior therapy and medications such as Prozac®.  It is uniformly true that Plastic Surgery to address the perceived deformity is never a good idea and in many cases can cause harm to the patient (psychologically).

The most common complaints have to do with the nose, face, and skin issues.  It is well known that the nose and facial features are psychologically charged ones even for those without BDD.  A poor self-image leads to a chronic loss of self-esteem and destroys any quality of life for those sufferers.  Referring these individuals for psychiatric evaluation is necessary, but seldom happens unless there is family support for the intervention.  I have also noticed a higher than usual incidence of anorexia and/or bulimia in these patients.

Realistically, as a plastic surgeon one should never be caught off guard by the BDD patient as these people have a very difficult time hiding their diagnosis even if they know they will be turned down for surgery.