Scabs and Scab-ology 101

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

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

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

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

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

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

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

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

What You Need to Know About Stem Cells

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

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

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

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

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

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

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

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

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

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

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

Aging & Fat Grafting for Facial Wrinkles

fat-grafting-for-wrinkles-and-lips

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

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

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

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

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

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.

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

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

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