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.

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 Ins and Outs of Rhinoplasty by Dr. Paul Howard

By its very nature, Rhinoplasty is one of the most personal of Plastic Surgical procedures.  Many people define the way they look and reflect their ethnicity on their noses and any changes anticipated must be fully discussed pre-operatively.  To do this the patient must have a firm and unwavering commitment to facial change as well as an honest and realistic expectation about the nose they wish to have.  This may start with a look through today’s fashion magazines to see what the “beautiful people” look like.  While it is rarely possible to recreate another’s nose, it does provide a starting point and does give the Plastic Surgeon a general idea of what the patient wants.  The process can then begin to alter the patient’s expectations to something nearer to reality.  Every patient should expect to have a more attractive nose that also breathes well, but not every patient can have the perfect little turned-up nose seen in so many of our current movie actresses.  Once the Plastic Surgeon gets a general idea of what the patient desires, then he/she can begin discussion of the details of the operation and what may or may not be possible.  During this part of the consultation, drawing expected results on the pre-operative photos or utilizing computer imaging is essential.  The only caveat regarding computer imaging is that it is always better if the operating surgeon does the imaging so that the imaged results are as close to realistic as possible.

Explaining the details of the procedure is important as the possibility of complications is hidden in these details.  For instance, describing a dorsal hump reduction should lead to the possibility of a small elevation at the bone-cartilage junction and in large reductions leads to a discussion of osteotomies and supra-tip problems.  We usually perform a septoplasty as straightening the outside of the nose can incur septal deviations that cause breathing difficulties if no septoplasty is performed.  Additionally, the sub-mucous resection of the septal cartilage can be replaced (banked) for possible future use or used to help define a nasal tip or to open an internal valve or straighten the cartilaginous dorsal septum.

The thickness or thinness of the skin needs to be addressed as each can affect the visualized result; thick skin will camouflage tip contouring while thin skin may show the tip architecture created in the finest detail.  Therefore, in a thin skinned patient more discussion of tip detail is crucial.  Explaining planes, cartilage breaks, and light reflexes may then become important.

The most important pre-operative information that must be understood clearly by the patient is that it takes at least 6 months and usually up to a year before the final result is realized and that any necessary revisions should wait at least 6 months in most circumstances.  It is important to not over-sale the cosmetic rhinoplasty.

From the Plastic Surgeon’s point-of-view, reconstructive and even cosmetic rhinoplasty is challenging and has a “steep learning curve” which means it takes a lot of cases to become facile with the instruments and the operation.  I personally was trained by one the best rhinoplasty surgeons ever (see: Rhinoplasty Tetralogy by D. Ralph Millard, Jr., MD).  My early practice encompassed a lot of broken noses due to automobile or physical trauma.  Then I gained a reputation for cleft lip and palate as well as the most difficult rhinoplasties on infants and children.  After 20 years of experience I now only concentrate on teenage and adult cleft lip rhinoplasties, complex rhinoplasty due to trauma and most cosmetic rhinoplasty.   After an extensive 26 year experience, I still find rhinoplasty to be the most taxing and the most rewarding operation that I perform.

Read more about Rhinoplasty by top plastic surgeon Dr. Paul 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 worshiper.  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; opportunity fleeting; 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 “blue-book” to help train young cardiovascular surgeons.

To learn more about Dr. Paul Howard, please visit his web sites:

PaulHowardMDcom

TheHowardLift.com

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

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.