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.

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).

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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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.

Rhinoplasty – Minimal Surgery with Major Results

There is a certain subset of patients who, by genetics or trauma, will require a true septo-rhinoplasty to correct breathing problems and to straighten an injured nasal pyramid.  There is a much larger group of patients who have relatively minor cosmetic nasal problems, usually confined to the tip or the bridge of the nose.  It is a well-known that the tip of the nose tends to lose its support as we age causing the nose to tilt over the upper lip and gives the impression of a longer nose.  Minor nasal tip cartilage problems can create the impression of a “boxy” tip or even a “pointy” nose.  Minor bridge problems can be addressed with small operations.

The use of filler in the nose has only recently become popular.  There are a few situations where fillers may improve the nose without surgery.  Small discrepancies of the nasal bones usually due to trauma and certain small tip and bridge asymmetries may be improved with the judicious use of fillers.  To this point in time the “perfect filler” is still your own fat.  Harvested and processed fat is long-lasting and usually does not require secondary procedures.

The nasal refining procedures do not require general anesthesia and are not covered by insurance.  These procedures are for refining the nose and as such do not change to overall ethnicity of your nose.  Think of your same nose yet more refined, elegant, and at a greatly reduced price.  For some people a major nasal reconstruction may be necessary due to trauma, for those who want a completely new nose, or those with significant nasal breathing problems.

Dr. Paul Howard

View rhinoplasty before and after photos on Dr. Paul Howard‘s web site.

Luscious Lips

Beautiful, full, pouty lips are considered youthful. One of the natural consequences of facial aging is the loss of normal lip volume causing a deflated appearance with wrinkling.  There are many misconceptions regarding attractive lips that seem to have found their way into the social consciousness due to plastic surgery results that seem to have gone awry.  Merely increasing the size or the amount of vermillion show (red portion of the lips) does not make lips youthful or attractive.  In fact, exaggerated lips seem to invoke the opposite response much like the overdone rhinoplasty, facelift, or breast augmentation.  It should be clear that exaggerated plastic surgery is a choice, not a necessity.  Plastic surgery has progressed do the point where overdone is not mandatory and we Plastic Surgeons should question not what we can do but what we should do.   Because a patient asks for bad plastic surgery doesn’t mean we are obliged to do it.   Our role should be to educate those who ask for things we know are unattractive and if no common ground can be negotiated, no surgery should be performed.

There are details commonly associated with youthful lips that are easy to achieve as long as you know what you are trying to achieve.  Full lips are youthful, grossly inflated lips are not attractive and reek of bad Plastic Surgery.  Full lips require replacing the lost lip fullness with natural material such as fat.  There are numerous off-the-shelf graft materials that seem easy to use, but as foreign materials they present a multitude of problems that make the result less than perfect.  Autologous fat taken from the abdomen or hips, when properly processed, provides the best graft material for lip augmentation.  Increasing lip volume causes some increased vermillion show (red portion of lips) seen from the front as well as increased “pout” as seen from the side.  The increased volume must be apportioned so that they appear fuller and pouty.  Other aspects of the beautiful lip include definition of the white roll, fully visible philtral columns, and important for a natural look, a lower lip that is slightly fuller than the upper lip.  These nuances are not obtained by luck, but rather because of detailed surgical planning using the correct filler material.  The results should be apparent immediately and should last a lifetime.  Continued aging may lead to the need for touch-up grafting after several years even though the transferred fat, once healed, is permanent even though the lips are a highly mobile area of the face.  Any perceived problems with graft “take” are generally due to poor harvesting of the fat and inadequate processing of the harvested fat.  One should expect to have the fullness lost since the teenage years. It can be helpful for your Plastic Surgeon to see high school photos for reference.

Dr. Howard has been a world leader in fat grafting for over 25 years.  Patients travel from all over the world for his fat grafting mastery to rejuvenate their appearance, or fat grafting for reconstructive procedures due to injury or birth defects.  To learn more about fat grafting for  lip enhancement, facial rejuvenation, or cosmetic hand rejuvenation please visit:

Read more about Dr. Paul Howard’s lip augmentation.

Lip Augmentation Before Picture Lip augmentation before photo
Lip Augmentation After Picture Lip Augmentation after picture

Laser, Light Savers, and other Fanciful Ideas

There are literally hundreds of companies developing, manufacturing, and selling laser systems to treat a wide variety of ailments. Some of these laser platforms actually work, but for the most part they never live-up to the expectations created by their marketing campaigns. There are many companies that sell the exact same technology as others but offer new “bells and whistles” as well as more attractive packaging. Doctors have a bewildering number of choices with conflicting claims of “remarkable” results. Complicating the marketplace even further is that the companies market their laser and other “do-dads” directly to the patient hoping that patient inquiries to their doctors will drive the marketplace rather than scientific studies which determine the efficacy of a specific laser treatment.

Concomitant with the latest marketing schemes a lexicon has evolved to describe the wondrous things these lasers can do. Certain words reappear frequently such as: powerful, pain-free, immediate visible results with superior comfort, fast treatment times, and the ubiquitous product that produces superior results and a great ROI (return of investment).

Besides shooting down enemy missiles (ICBM) and providing the “red dot” for laser guided weapon systems, today’s lasers are useful but not required to treat the following: tattoos, vascular skin lesions, superficial facial wrinkles, acne scarring, and for skin rejuvenation in its most generic form. It is human nature to want to look younger with no surgery, no down-time, and no pain. Unfortunately, this is rarely if ever possible. The best plan is to consult first with a physician you trust that has knowledge about Plastic Surgery and skin rejuvenation. Hopefully he or she can help you make sense of the aesthetic industry and give you useable information regarding your particular wishes. Many times a laser may not be necessary at all when much simpler explanation and recommendation will suffice. Sometimes common sense will lead you to the right answer. It is always true that a claim that is too good to be true frequently is.

There are a number of newer technologies now available that are not lasers but make fanciful claims. Intense Pulse Light (IPL), cold therapy (Zerona®), mesotherapy, and radio frequency (RF) tissue healing are out there with little to no data proving their efficacy. A very thoughtful Plastic Surgeon once said, “I’d rather not be the first to jump on the new technology band wagon, nor do I want to be the last.”

Dr. Paul Howard is Board Certified by the American Board of Plastic Surgery. To learn more about Dr. Howard and his Plastic Surgery practice in Birmingham, Alabama please go to his web site:

PaulHowardMD.com