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

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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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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

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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.

Smoking and Plastic Surgery

Patients who smoke are a problem for plastic surgeons for multiple reasons.  It is a well-documented fact that smokers are much more likely to have wound complications especially with procedures that require undermining the skin such as face lifts and tummy tucks.  Smoking also affects the healing of all incisions whether undermining or not, and I think smoking is one of the causative factors for capsular contracture of breast implants (hardening of the breast implants).  Even those incisions that appear to heal initially are more likely to open after the sutures are removed and usually produce poor scars both in quality and appearance.  In scars that technically heal without “complication,” the period of time it takes for effective healing of incisions is longer than for non-smokers.  Once incisions have failed to heal, primarily the problems escalate.  In addition to poor quality scars, these incisions act as though they have an inadequate blood supply similar to scar healing after radiation therapy.  Open incisions are prone to bacterial infection and require a great deal of time and effort for local wound care.

Inhaled cigarette smoke also causes damage to living tissue causing bronchitis, wheezing, and eventually emphysema.  Intrinsic lung damage complicates the administration of general endotracheal anesthesia and blood oxygenation.  These pulmonary problems with smoking are not exclusive to plastic surgery patients, but nonetheless should be counted in our complication list for smokers.

There are several things that plastic surgeons can recommend to the smoker to mitigate some of the problems caused by smoking thereby reducing but not eliminating complications.  The most important thing a smoker can do is stop smoking.  There is data that suggests stopping smoking for two weeks before surgeries decreases smoking related complications.  A good pre-operative evaluation may uncover some pulmonary related problems such as congestion associated with bronchitis or bronchospasm.  Early recognition and treatment of those problems may reduce the pulmonary related complications.  Personally, I believe that staying away from general anesthesia if possible decreases smoking related risks.  Full monitoring with local anesthesia plus sedation decreases complications for smoking and stabilizes swings in blood pressure for both non-hypertensive and patients with hypertension.

Only those patients who refuse pre-operative instructions and cannot or will not stop smoking should not be accepted as a candidate for elective cosmetic surgery.  It is not clear if the wound problems are secondary to nicotine alone or a combination of nicotine and other toxic substances associated with cigarette smoke.  The data is unclear if using nicotine containing products to stop smoking causes the same level of wound problems associated with smoking.  Chantix® is a good alternative to stop smoking without using replacement nicotine (Nicorette®, etc.)

Patients should be careful to create a healthy non-stressful environment.  Recovery in a smoke-free environment is extremely important as second-hand smoke has been shown to be as harmful as first-hand smoke to wound healing.

PaulHowardMD.com

Men & Plastic Surgery

Men pay for approximately 80% of the cosmetic surgery performed while becoming a patient only 20% of the time.  It is hard to know if this is indicative of the social taboo regarding men and cosmetic surgery or is it a result of the idea that men are much less stoic than women and are basically averse to the minimal discomfort involved.  Regardless of the cause, men are more frequently having plastic surgery and generally have the same reasons for having cosmetic improvement as our women patients:  improved self esteem, being competitive with younger people in the work place, and to appear more youthful and attractive to the opposite sex.

Men age somewhat differently than women and require surgeries that are tailored for their specific facial aging issues.  For instance, men are more likely to complain about their necks while women focus on the midface/cheek area.  Both men and women have upper and lower blepharoplasty but men rarely want the browlift procedure so as to not look like “Kenny Rogers.”   Kenny Rogers is a well known celebrity, singer, actor and country music star who was the unfortunate victim of an overdone browlift – forehead too tight, too smooth, too high, thus totally changing his appearance for the worse.  In addition to eyelid and neck rejuvenation men are likely to inquire about liposuction of the waist and abdomen area. Men desire a nice tight, jaw line and neck with a youthful profile, a sculpted waist and bright, open, uncluttered, youthful eyes.  Post-operatively, men tend to go back to work too quickly, tend to bruise worse than women, and are less likely to follow post-operative instructions.  Men and women both require a full dose of positive reinforcement throughout the healing process.  Early and often post-operative photos to document healing and cosmetic improvement are helpful during the early stages of healing where bruising and some swelling is to be anticipated.  Men are less likely to keep all of their post-operative appointments and tend to be more secretive regarding their surgery than women.  Men are uniformly less patient while healing but more appreciative of the good results and more youthful appearance over time.  Men are less likely to have researched the procedures they want and tend to be referred mostly by other patients and thus are less affected by marketing schemes than women.  Terminology is also important to men who shy away from the term “facelift” but respond well to being offered a “necklift.”  Even with their idiosyncrasies, men are generally some of our most appreciative patients.

Dr. Paul Howard

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A Primer on Liposuction

The development of liposuction about 30 years ago was driven by our patients who asked for a method to reduce body fat without the scars associated with the usual tummy tuck procedures.  Our primary focus is the safe removal of isolated pockets of fat to improve body contours.  While the goal (fat removal) has always been the same, the methods of anesthesia for liposuction have changed through the years making the procedure more “patient friendly,” yet achieving the same contour results.  Most of the technological advances are intended to make the fat removal easier and, even more importantly, an attempt is being made to tighten loose skin and improve the appearance of cellulite utilizing the latest surgical laser technology. Most plastic surgeons believe that the skin tightening effects have not been as impressive as the manufacturers claim.  Each manufacturer slightly alters the laser platform so their product can be claimed as “unique” while there is no discoverable clinical difference in the final result.  Laser assisted liposuction is marketed under any number of trademarked names including Smartlipo, Vaser, Slim Lipo, Cool Touch, etc.  The marketing department of the manufacturer uses the trade names to market these laser liposuction platforms directly to the patients.  The laser can be purchased by ANY practitioner, even those with no laser or surgical training.  Regardless of the laser manufacturer, the practitioner is told that the patient referrals will be generated through their web marketing and the practitioner is allowed to use the trademarked name (Smartlipo) in their practice marketing efforts.

This marketing strategy is similar in design to the pharmaceutical companies who advertise their drugs directly to the public and offer the names of certain physicians who prescribe their products.  All of these marketing schemes are evidently legal, but in the laser liposuction example, the machines are sold to any doctor with the money, training is offered but not required, marketing and patients are guaranteed without checking the doctor’s credentials.  The red elephant in the room is that laser liposuction is inherently more dangerous than standard tumescent liposuction techniques and in many instances is performed by non-plastic surgeons who are damaging their patients because of a lack of basic education and the need to market the trademarked product that they own rather than choosing the proper technique for each individual patient.

Many of these doctors ask you to ignore their training and credentials and emphasize their marketing skills.  In the final analysis, patient education is not advanced with unclear or even false advertising and many people have suffered as a result.

The MidFace Lift

Facial aging is complicated by genetics, environment, sun damage, smoking, and drinking.   There is not a single procedure that works for everyone, therefore it is important that individualized evaluation leads to an operation which is specific for that person.  The uniqueness of all faces as well as the patient’s desires may lead to a slightly different surgical approach for each individual.  Another way to say this is that the one-size-fits-all facelift has become antiquated.  To facilitate individualized care we prefer to look at each part of the face separately leading to a unique surgical treatment plan.

We divide the face into its component parts; forehead, eyes, midface, and neck with primary emphasis on the midface.  Midface aging is characterized by sagging of the facial soft tissues causing a deepening of the nasolabial folds, dark circles beneath the eyes, and the development of marionette lines from the corner of the mouth to the jaw line.  The jaw line becomes less defined as the sagging facial soft tissues drop below the mandible causing jaw line “bubble.”  In addition to the sagging soft tissues aging always involves a loss of volume and a loss skin elasticity.  It is the surgeon’s charge to address individual manifestations of aging for each component part of the face.  Elevating the soft tissues must be done and requires a specific vector or direction of elevation which may be unique for each face.  This maneuver defines the jaw line, improves the deep nasolabial folds, addresses the marionette lines, and elevates the lower eyelid skin.  This procedure is always required and must be performed accurately with minimal incisions.  Elevation of the cheek tissues is so important that it must be done under direct vision with the results being technique dependent.  The incisions are much less obvious than the old facelift scars.  While elevating the cheek and malar tissues some augmentation of the malar prominence (cheek bones) is achieved.  The need for additional volume can be affected by adding autogolous fat to the procedure.  As a rule of thumb, we rarely, if ever, remove fat from the midface but frequently add fat back to replace the soft tissues we lose over time.

The next issue to be addressed is the blending of the cheek elevation with the lower eyelids.  These procedures are typically done together; that is lower blepharoplasty and mid-face lift.  The elegance and effectiveness of the mid-face lift sets up the rejuvenation of the remaining parts of the face.

Read more about Dr. Paul Howard’s Howard Lift Facelifts

The Modern Browlift by Paul Howard, MD

There are a number of techniques to smooth the forehead and elevate the brow.  Practitioners always tout the technique they use as being the “best” but more likely the procedure some view as “the best” is primarily the operation they are more comfortable with.  Surgeon’s comfort should not triumph patient results for browlift or any procedure where the results of the two procedures are different.

The antiquated browlift requires an incision in the forehead skin – the so-called “direct browlift.”  In an attempt to hide the scar and elevate the brow without the hairline, surgeons flocked to the pre-hairline incision and many claim the very long incision is easy to camouflage and causes no problems.  Common sense belies these claims and most surgeons have abandoned this procedure due to the scarring involved.

The last 10 years has seen the development of endoscopic techniques which minimize the scars by placing the two short incisions behind the hairline while allowing access to the three glabella muscles and the forehead muscles from beneath the skin.  Elevating the brow must be accompanied by some sort of fixation to hold the forehead skin and brow in the raised position for at least 2 weeks. The brow elevation may relapse to its pre-operative position without fixation while the muscle surgery used to decrease glabellar rhytids (wrinkles) and sometimes forehead wrinkles is not fixation dependent.  These rhytids are improved by effectively weakening the forehead and glabellar muscles that cause wrinkles.

Over the last 8 years or so we have developed a unique and quite elegant way to fix the brow and forehead in the raised position with bio-absorbable screws that dissolve after the golden 2 week period of required fixation.  The polymer chosen must be strong enough to withstand screw placement in bone, must maintain its bio-mechanical properties for at least 2 weeks and must eventually be cleared from the body.  The material chosen is a co-polymer of polylactic acid.

The “Modern Browlift” is a well researched procedure with at least 8 years of documented results, short incisions, no hair loss, no prolonged numbness in the scalp and minimal to no elevation of the hairline.

Read more about brow lift and view brow lift before and after photos.

Call today to schedule your consultation 205-877-PAUL

The Perfect Facial Filler by Dr. Paul Howard

Botox and Restylane have become the mantra for those seeking facial rejuvenation without the inconvenience of having a “surgical procedure.”  While these off-the-shelf products are enticing, they are expensive, temporary, and can be painful to inject, especially in the lips.  For more Plastic Surgeons, these artificial fillers (Restylane, Juvederm, Strattice) are appropriate only for temporary improvements where there are time constraints and the need to be in public within a couple of days.  Searching for the perfect facial filler had been elusive until recently.  The emergence of fat from your own body (autogenous) has paralleled the refinements in fat harvesting and injection techniques that have elevated the “take” of fat injections to the 80-90% range.  Coupled with improvements in local anesthesia and anesthetic agents make the overall experience with the new fat injection techniques less painful and more likely to give a permanent, elegant improvement in facial contours and rhytids (wrinkles).  Many non-surgical practitioners complain of the donor site for obtaining the fat.  While we must respect the donor site, offering the patient an improvement in body contour by harvesting fat for injection offers the patient the benefits of a liposuction (method of harvesting fat) procedure and cosmetic improvement of the donor site as well as the areas of the face injected with fat.

What does the future hold for facial fillers?  Ongoing research using stem cell and growth factor technology may lead to even further improvements in fat injection techniques while artificial filler research tries to make their artificial substances last longer and the cost with longer lasting substances is naturally higher and will continue to increase over time.

Fat injection techniques have proven to be a vast improvement over foreign-body injections for facial rejuvenation.  Fat is permanent, soft, cannot be rejected by the body, natural, and requires only small (3-4mm) stab wounds for injection.  The patient can request which body area is preferred as a liposuction donor site obtaining body contour improvement at no additional charge.  The well informed patient will usually choose the elegance of fat injection over the expediency of foreign material injected in the face.

As an extension of fat technology, we have begun fat injections in the back of hands for hand rejuvenation.  The injected fat decreases the appearance of prominent veins, knuckles, and tendons that become more pronounced as we age.  No one should let their hand reveal their age when we have the procedures to reduce the signs of the aging hand.

Read more about top fat grafting surgeon Dr. Paul Howard and view fat injection before and after photos.