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% or 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.  Safety issues are being addressed due to the fact that there are an increasing number of reports describing bleeding

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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

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On the Training of Horses, Linebackers, Pilots and Plastic Surgeons by Dr. Paul Howard

The critical reader may come to the opinion quickly that I am only a Plastic Surgeon and probably know little about training horses or football players.  While this is essentially true, I don’t believe it disqualifies me to comment on other fields of endeavor that require many of the same complex skills that are inherit to the Plastic Surgeon.

The training of surgeons is unlike any other field of endeavor.  One can read massive amounts of material, study diligently for four years of medical school, memorize the indications for an operation, actually study the pertinent anatomy and how to perform an operation and yet know virtually nothing without taking the final exam by incising the patient’s skin and performing an actual procedure where the stakes are as high as they can be.  This discipline is entirely different than any other medical specialty as the requisite study of disease is not the endpoint of training, it is the ante that allows one in the real game which is the application of knowledge to perform a mechanical skill (surgery) which is basically unnatural and requires skills that are not genetic but entirely learned.  Since surgery is learned behavior, there is no way to be graded except by the subjective appraisal of a competent surgeon.  As time evolves and the surgeon becomes independently proficient, the grading of results requires continuous, honest self-assessment of one’s results.  The built-in weakness of the surgical training paradigm is the quality of the “on-the-job” training.  This is the primary reason why surgical, and more specifically, Plastic Surgical training, can lead to widely diffuse results in the quality of the surgeon.  These facts became self-evident to me and led me to seek the most talented and well known surgeons of my era of medicine.  Since we learn surgery by watching and imitating others, it makes perfect sense to seek the best to emulate.  This quest is how I came to know John Kirklin, M.D, Ralph Millard, M.D, and Paul Tessier, M.D.  For those who are unfamiliar with the names, these are the best of the best in surgery.

Let me begin by admitting that I am a hero worshipper.  It happens that I have a small but unique set of personal heroes that I have accumulated over a lifetime.  These men have excelled in their respective fields which happen to include the thoroughbred racing business, the aircraft industry, the National Football League, and the field of Plastic Surgery.

Those who only know horse racing by watching the Kentucky Derby the first Saturday in May every year are not privy to the complexities of thoroughbred breeding, training, and racing.  You may notice the atmosphere in Louisville, KY at Churchill Downs includes beautiful hats and the unfettered consumption of Kentucky bourbon in the form of the ever present Mint Julep.  This pageantry belies the complexity of horse genetics and gene pools as well as the training of these extremely fragile animals.  Additionally, they are trained to race beginning as a two year old animal.  The three year olds that race the Derby are still adolescent animals and behave in many ways the same as our teenaged children.  Yet, the results of their early races can lead to a multi-million dollar horse, both as a racer and later as an addition to the thoroughbred gene pool.

Dr. Ruel Cowles is a veterinary physician/surgeon whose practice and life is dedicated to the healthcare of these majestic animals.  One of my mentors, John Kirklin, MD, was an established horseman and was convinced that race horses were essentially untrained whereas gaited, dressage, and jumpers were the only horses truly trained.  Dr. Kirklin also opined that a good jumper must be at least 10 years of age.  Racing 3 year-olds in packs of 10-20 over a mile long course against the best 3 year-olds in the world would probably be a daunting task for a 10 year-old thoroughbred.   It’s like training a 15 year-old to pitch in the major leagues – you can never be sure exactly what you will get.

Dr. Cowles embodies the best of clinical veterinary medicine as well as the intellect to excel as a horse breeder.  Dr. Ruel Cowles is one of my heroes.

I have more than a passing interest in the sport of American Football.  I was, as many of my colleagues were, a high school football player.  I managed to keep my NFL dreams alive through my first year of college where the physical and mental rigors of the game caused me to turn in my shoulder pads to pursue academics full-time.  As such I developed an almost unhealthy respect for those players who made it to the NFL.  I particularly liked linebackers as that was my chosen position.  The day I met Kevin Greene, at the time playing for the LA Rams, I realized who I would have become if I had the fortitude to continue playing.  Kevin was a walk-on at Auburn University in the early 1980’s under Coach Pat Dye.  He showed early on his pass rushing prowess, but only a few NFL scouts agreed and was chosen by LA in the sixth round of the draft. From his first training camp, Kevin’s coaches and teammates understood that going easy on the veterans was not part of his game.  All Pro offensive tackle Jackie Slater found out Kevin was a “maniac” on every play, pre-season or not.  Kevin was soon inserted in the line-up for the Rams and there he stayed.  After leaving the Rams for Pittsburgh, he truly found his identity, grew his hair to his shoulders, married a beautiful Alabama girl, and became a favorite in Pittsburgh because of his aggressive and relentless style of play.  He was known for sacking the quarterback but in fact was a complete linebacker in the 3-4 scheme.  I cannot remember a single time that a running-back or receiver managed to even fall forward after he got his hands on them.  I was privileged to be Kevin’s friend through the entirety of his 16 year NFL career including multiple Pro Bowls and defensive linebacker awards.  His intensity and dedication to his craft were unparalleled.   Ten years after his retirement from the NFL, he still holds the career sack total among linebackers.  Today, Kevin is imparting his knowledge to younger players as the outside linebacker coach for the Green Bay Packers.  Kevin is also one of my heroes.

I’ve known but a few fighter pilots and one submariner personally.  There are a few common traits these people have that separate them from the rest of us.  First, they all have very acute and agile minds that can assimilate knowledge quickly and apply it so that they are constantly evaluating their performance and improving by self-evaluating and reflection.  These traits are similar to those needed for Plastic Surgeons with the added immediacy of going Mach II or being thousands of feet under water.

As a first-year resident under Dr. Ralph Millard, I became acquainted with Dr. Gregory Lovaas senior resident under Millard.  Greg was like a xenon light in a room full of candles.  He shown brightly and was a wonderful teacher to me.  Knowing Greg as I did it was not easy to imagine the government putting him in a single seat F-104 fighter with nuclear weapons.  As I learned more about Greg, I realized he was the perfect personality for such a dangerous, in-your-face profession.  Greg, as most intelligent people do, had a wondrous sense of humor that may or may not have served him well over the years. My most vivid memory of Greg is the fighter pilot/Plastic Surgeon maniac.  He taught me the fighter pilot credo – “sometimes wrong, never in doubt.”  Greg Lovaas is one of my heroes.

A young boy and his twin brother grew up fatherless during the Great Depression in rural Griffin, Georgia.  Times were tough for everyone and the twins did the best they could for themselves and their family.  As they became teenagers, sports helped fill their days.  It was an accident playing baseball that knocked out the two front teeth on one of the boys causing a speech impediment and a lasting impression as he did not have enough money to receive the necessary dental care.  The twins with no prospects on the horizon lied about their age and enlisted in the Army and the Navy.  The story goes that the twins couldn’t understand why the new recruits were homesick and even cried at night while the twins were elevated from their Hell to three square meals a day and they weren’t worked very hard.  The addition of free dental care made WWII a life altering experience, all for the good.

New pair of shoes, one suit, two new teeth and training in electronics were enough to start a new life several years after the war with a new wife and further training in repair of the new-fangled American commodity – the television set.  The younger of the twins was desperately trying to live the American Dream.  Fixing the notoriously unreliable TVs and their vacuum tubes was a decent job.  Utilizing his military training and hands-on electronics experience, twin got a job with Lockheed Aircraft in Marietta, Georgia where he taught electronics to the new hires needed to build the C-130 “Hercules” and the new super airliner – the L-1011.  The younger twin learned he had a knack for teaching and especially training people to do a job.  He eventually parlayed this experience into industrial training programs for four Southern states eventually having a training facility posthumously named after him in Montgomery, Alabama.  Twin number two, and one of my heroes, was George L. Howard, my father.

The training of Plastic Surgeon is a long grueling process due to massive amounts of material to learn, but more importantly the aptitude, mental acuity, and complex decision making necessary.  Most students of Plastic Surgery realize that the training is so long (± 6 years) because the depth of knowledge necessary is vast and by necessity practicing Plastic Surgery requires a malleable mind to attack each challenge with freshness, intensity, and thoughtfulness. These attributes are not something one can read about, but can only be obtained by acquiring the knowledge from others who already have it.  This is why it is so important to ask the credentials of a Plastic Surgeon so one can surmise the quality of his/her education in Plastic Surgery.  In Plastic Surgery, it makes perfect sense that truly the best Plastic Surgeons are the best teachers.  My final heroes are two of my Plastic Surgery mentors that encompass the best that our field has ever created.  D. Ralph Millard, Jr., M.D., and Paul Tessier, M.D. are also my heroes.

Recent history has taught us the penalty to be paid by the consumer of Plastic Surgery who is swayed by the exquisite marketing of doctors who believe for financial reasons that the least amount of education in the intricacies of Plastic Surgery is somehow better than the full training program that has been in place for 30 years.  There is no other example of attenuated training in any of the surgical specialties.  Neurosurgeons are required to train in all aspects of neurosurgery and even take a year of basic neurology training even though few neurosurgeons practice all of the aspects of the specialty.  This is mainly because for the last 100 years it is clearly shown that almost all specialists benefit from a wide and diverse basis of knowledge leading to calmness under pressure and the ability to elicit a laser-focus required of the expert.  This is true for training many kinds of endeavors and one will never find a short-cut to the training of the best race horses, NFL linebackers nor in the making of aircraft or the training of Plastic Surgeons.  Hippocrates said it best in his aphorism “Life is short, and the art is long; opportunityfleeting; experience perilous, and decision difficult.”  The first time I heard this warning was from the great cardiac surgeon John Kirklin, M.D. in his famous surgical “bluebook” to help train young cardiovascular surgeons.

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Gynecomastia by Dr. Paul Howard

Gynecomastia is a deformity that usually manifests in teenage boys where there is massive hormone stimulation of the nascent breast tissue causing enlargement associated with pain and a very disturbing physical deformity.  Gynecomastia tends to run in families therefor there is some genetic component and usually becomes manifest in the early teenage years when male hormones are active.  It is usually associated with mild to moderate torso obesity.  The deformity is worsened by weight as there usually an aspect of the deformity that is fat tissue in addition to tender breast tissue.  It is that fat portion of the deformity that has caused insurance carriers to demand weight loss as well as hormonal studies to document and treat the disease.  There are insurance carriers who specify in their contracts that they explicitly do not cover gynecomastia resection under any circumstance.

The treatment of gynecomastia in adolescents should include, if necessary, an attempt at weight loss followed by surgical resection, usually tumescent liposuction technology.  Unfortunately, if surgery is performed in the early to mid-teenage years there is a possibility of recurrence, usually beneath the nipple/areolar complex, as it is virtually impossible to remove the breast tissue in its entirely.  Additionally, any upper fluctuation in weight will also give the appearance of a recurrence.

Gynecomastia in adult males is usually due to excessive marijuana smoking and/or abuse of anabolic steroids or large doses of testosterone.  Most men who fit this profile are body builders with a reasonable low body fat. Those with higher body fat percentages also have a fatty component to the deformity.  Most body builders who “stack” their anabolics also take an anti-estrogen drug trying to prevent the painful breast enlargement.  Surgical removal for pain relief and cosmetic chest improvement usually requires direct excision.  These men usually have hypertrophic and highly vascular chests causing common hematoma formation post-operatively.  Again, recurrence can be common if the patient continues to use steroids.

Gynecomastia, especially the teenage version, occurs at a very unsettled age when there may be extreme body dysmorphism.  Children this age can be unpleasantly negative at a time when undressing for the gym or going to the swimming pool can be a traumatic event.  These psychological issues are reason enough to operate early even if a re-do becomes necessary.

Call today to schedule your consultation with Dr. Howard 205-877-PAUL

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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.

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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.

Joggers and Runners: Beware

In our current healthy and image conscious environment many people choose to maintain fitness by running, jogging, or high impact aerobics.  While these exercises are great for cardiovascular fitness they are extremely bad for facial aging.  First and foremost facial aging is primarily a result of loss of skin elastic tissue due to sun damage, environmental factors and smoking.  Pounding the pavement has an adverse effect on facial aging in the face of poor skin elasticity.  Compression garments can be worn to hold firm abdominal, thigh, and buttock tissues as protection against the effects of running on these tissues.  No such garment can protect the face from the deleterious effects of extreme exercise.  Runners are usually thinner than others of the same age.  It is a well-known fact that while healthy, thin faces age quicker than faces with some fat content.  The opposite is true for necks – little fat in the neck is good whereas a fat neck is difficult to contour.  Many people who exercise heavily do not maintain adequate hydration.  Drinking large amounts of water help keeps skin hydrated and less likely to manifest dryness, fine wrinkles, and laxity of aging.  There are plenty of aerobic exercises and machines that provide a serious workout without the up and down pounding that can exacerbate the facial aging process.