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Entries by Brian Howard, MD, FACS (3)

Tuesday
Nov272012

Stem Cells and Regenerative Medicine - Ready for Prime Time?

The future looks promising for stem cell therapies in aesthetic medicine.

The arguments for and against the use of stem cells for research and medical therapeutic applications have existed for decades and will no doubt increase in volume and intensity for some time to come. Vast amounts of public and private money are currently pouring into the research for these polarizing fields and a Google search on these topics will populate dozens of new articles not only domestically but also globally on a daily basis. The hopes of uncountable patients and their family and friends are intricately entwined on unlocking possible therapeutic applications to cure a myriad of maladies from spinal cord injuries, Alzheimer’s disease, diabetes and heart failure to rare genetic disorders that claim the lives of children daily. In short, stem cell research and regenerative medicine are in the early explosion phase of discovery, application, and no doubt ongoing controversy.

Initial shockwaves of fear and objection arose partly from the need for using embryonic stem cells for this research.  Fortunately, it is looking more promising that we can use easily obtainable cells from existing and abundant adult tissues and engineer highly selected cells from these tissues to become culturable and guidable stem cells. Ideally, this would negate the use of embryonic stem cells and eliminate at least this one-of-many passionately debated aspects of controversy (there are many!). To date, cells from bone marrow, skin, and adipose amongst others are being used to isolate adult stem cells, and from these it is hoped that we can “reverse engineer” them into pluripotent cells that can be used to generate selected tissue types for clinical use. How many of us don’t have an extra area or two of excess fat that could potentially be used to save our life at some point in the future?  While we don’t have proven reliable human applications as yet, the future does look promising. I am seeing more and more presentations at our plastic surgery meetings on stem cell research and regenerative medicine and the buzz and excitement are palpable. It is important to note that all involved seem to share a sense of cautious optimism and emphasize the need for careful control over the research and applications.  The FDA is very involved with all aspects of clinical use of stem cells as the field evolves and becomes more complex.

The future is exciting for stem cells and regenerative medicine. I fully agree with careful oversight and deliberate planning and control as research progresses. I follow the fields closely and am hopeful that in the near future we can offer hope to those patients with difficult illnesses and medical conditions that are currently not largely treatable. And all the better if we can obtain easily available and harvestable tissues to affect the research and clinical applications. Now I invite a lively and constructive discussion from the readers!

Friday
Sep072012

Painless Neurotoxin Injection Method? Join the Discussion!

What injection methods are most useful and reliable for neurotoxin injections: Botox & Dysport.

I have been in clinical private practice going on 14 years now and enjoy a busy and healthy cosmetic surgery practice.  Injectables, both fillers and neurotoxins, remain an integral part of my practice and I suppose that the loyalty my patients show by continuing to return to me as their injection provider is testament that my skills must be competitive with the many other local physicians who offer the same procedures.  I definitely do not price cut to keep the volume or attract new patients, and I believe I price fairly taking into consideration both my training and experience with typical pricing in my area by "mainstream" cosmetic providers.

I continue to strive to offer the least painful experience for my patients and have tried multiple different methods to decrease the degree of injection discomfort for my patients.  From topical anesthetics, icing, slow injection delivery, and currently vibration-distraction techniques, I have yet to find the WOW approach. I do use lidocaine-treated fillers and believe that these have advanced our patients' injection experience to an appreciable degree.

My intent for this entry is to stimulate a healthy community discussion on what methods the readers have found useful and reliable for neurotoxin injections (to keep this discussion focused I am not encouraging discourse on filler injections but perhaps this can be a future topic of discussion), in addition to disregarding any approach that they have found particularly not beneficial.  We all want to make our injections as easy as possible for our patients, so I am hopeful that this topic can generate healthy dialogue!

Saturday
May262012

Laser Liposuction & Skin Tightening - Emperor's New Clothes?

Laser Assisted Liposuction - Medical Spa MDDoes laser assisted liposuction really provide all of the skin tightening benefits that the manufacturers claim?

We are in pursuit of many Holy Grails in plastic surgery, from scarless post-surgical healing, non-invasive liposuction and implant-free breast augmentation to non-invasive skin tightening. With the advent of laser-assisted liposuction (LAL) came the promise from the manufacturers that we have finally achieved a way of combining "minimally invasive" fat removal with skin tightening, sensationally treating two maladies with one procedure.

I been involved with LAL for many years, and it has been the primary revenue driver in my practice for nearly five years running. I began to perform the procedure when the machines became powerful enough to actually generate enough subdermal heat in a timely fashion to potentially create significant collagen remodeling and hopefully result in skin tightening. My case load quickly became large enough that I was asked to be a national speaker for one of the dominant laser companies educating other physicians on the use of LAL. As such, I delved into every published paper even remotely relating to heat-generated skin tightening and laser assisted liposuction. Over the years, I have been able to merge a huge surgical experience with the science behind the procedure and draw some fairly clear and simple conclusions on the issue of skin tightening.

Setting up a patient for potential skin tightening is fully dependent on generating ample subdermal heat to initiate collagen denaturation and subsequent remodelling. Generally, this temperature is felt to be between 40 to 45 degrees celsius.  At around 47 degrees celsius, skin blistering and burns occur.  With proper time, temperature-monitoring devices, and careful technique, adequate temperatures can be achieved. Getting the skin to this temperature range takes time and significantly prolongs the procedure. Additionally, the risk of seroma escalates the longer you spend with the tissues in this temperature range in my experience.

In about 15% of cases, I see clinically visible skin tightening which I don't feel I would have seen using other techniques. This skin tightening is not the equivalent of excision techniques, but typically limited and subtle. This is obviously purely my subjective opinion to be clear, and I cannot say that these same results may not have occured witht the same frequency had I used other liposuction techniques.

The science of LAL and skin tightening is clear that some tightening does occur and is quantifiable. But this does not predictably translate into clinical relevance. I have now performed nearly 1000 LAL's and no longer educate my patients that LAL is a good method of tightening skin. The limited degree of tightening I credit LAL for is not enough to call it a clinically relevant skin tightening procedure. The majority of new LAL consults in my practice present with the impression that LAL is going to tighten up their loose skin while removing fat. The notion is dominant on the internet and even in print ads. I politely educate them that although there may indeed by some skin tightening, this will be subtle at best. In my opinion, the advantages of LAL lie elsewhere, particularly in a somewhat easier recovery.

I continue to hear from colleagues who also use LAL that they believe in the skin tightening.  I don't know if this is a case of "The Emporers New Clothes" or not. I have pushed the envelope in terms of thoroughly heating up the skin to appropriate temperatures and length of time, but only see minimal tightening and an increase number of seromas. I continue to use LAL heavily but no longer tout skin tightening as being an expected end point.

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