Face Lifts For Smokers.

A new study suggests that cosmetic surgery could help a patient quit smoking long term. Most surgeons in North America suggest a cessation period of 2 weeks before surgery. However, it was found in previous studies that those who ceased smoking 4 weeks prior showed lesser rate of complications. Nineteen (19) percent of patients in their research attained complications. A follow-up was made by the researchers stating that only 10 of their patients have not smoked since their surgery.

Previous studies also delved in cosmetic or plastic surgery and smoking cessation.

In a study conducted earlier in the year found that there were postoperative complications as expected. The study was on a larger scale examining more than 40000 patients. However, among the 40425 patients in their study, 15.7% were smokers. Additionally the researchers of the study found that smoking had an effect as to where the procedure had been done.

Findings:

• 3376 (8.4%) patients incurred postoperative complications
• 732 (1.8%) patients had medical related complications
• 1611 (4.0%) patients had wound related complications

There were surgical complications for patients who underwent breast reconstruction, craniofacial/head and neck, and upper and lower extremities. Wound-related complications were found for craniofacial/head and neck and upper lower extremities patients.

E-cigarettes are no exception either since it contains nicotine. In 2016, a study focused on the use of e-cigarettes and if it has lesser detriments as compared to regular cigarettes. The effects weren’t as severe, but it did not eliminate the incidence of complications.

Additionally, according to many plastic surgeons, they have a smoking cessation session prior to surgery. Despite some efforts to do so, several patients had also reported smoking before their surgical procedure. It is unclear whether cessation intervention helped the patient quit smoking prior and after surgery.

The New "Natural" Breast - Ideal Proportion is Key

A recent study in the Journal of Plastic and Reconstructive Surgery reveals the ideal proportions that may be used as a basis for helping your patients define the perfect breast.

You've all seen it happen; every woman wants perfects breasts and is convinced she knows what that means. Why then, is she dissatisfied when you deliver the modifications she's asked for? It turns out there's a new standard of beauty and a new study to help you, and your clients, achieve it.

In a recent survey, 1,315 men and women were asked to rate the attractiveness of breasts shown to them in three-quarter profile.  The results showed a clear pattern; the best chests have 45% fullness above the nipple line and 55% fullness below in a slightly teardrop shape.  Upward pointing nipples, a mildly concave upperslope and a convex and smooth lower slope were also key. Ironically, the traditional emphasis on upper pole fullness is not what patients now want. Round is out, natural is in!

So, how do you transfer the old ideal to the new real? Use these tips to guide your consultation:

• Educate - find out what she already knows about the procedure and use this  knowledge as a basis to discuss the safest and healthiest way to achieve the result. Augment what they "know" with your expert medical opinion.
• Communicate - Eveyone woamn has her own opinions about ideal shape and size. It is also critical to know whether a natural or augmented look is desired. Also useful is a  discussion of implant location, fill material and resulting profile in addition to size. It is also key to help her understand that a naked breast will have a shape that differs from a clothed breast.
• Be specific - Size and proportion alone isn't enough.  Discuss frame size, body shape and activity level with your patient.
• Use images - Pictures, drawings and 3D imaging are all excellent tools to guide the process.

In the end, a common standard of beauty may be ideal, but your goal is to also help a woman be beautifully real.  If beauty is in the eye of the beholder, use her as a collaborator to achieve both of your goals.

Read more about the survey discussed above at: http://journals.lww.com/plasreconsurg/Fulltext/2014/09000/Population_Analysis_of_the_Perfect_Breast___A.8.aspx?WT.mc_id=HPxADx20100319xMP

Improved Method for Treatment of Burns

The use of meshed split skin autographs (SSGs) combined with autologous cultured proliferating epidermal cells provided better wound healing and less scarring compared to using SSGs alone.

In a 40-patient clinical trial, researchers from The Netherlands found that such technique provided better results for patients who suffered serious and deep burns. The usual method of treating burns was the use of split skin autographs.

The new technique developed by the researchers used autologous (self-donated), cultured proliferating epidermal cells that were “harvested” from a small donor site, and “seeded” in a collagen carrier that could, in theory, enhance the wound healing rate and improve scar quality.

Dr. Shinn-Zong Lin, Vice-Superintendent for the Center of Neuropsychiatry, professor of Neurosurgery at China Medical University Hospital, and coeditor-in-chief for Cell Transplantationwas quoted saying that this study offers a promising, improved therapeutic method for treating severe burns.

According to Dr. Esther Middelkoop of the VU University Medical Center in Amsterdam, a co-author of the study,

The rate of epithelialization in the experimental treatment was statistically significantly better when compared to the standard treatment. We also established improved pigmentation for the wounds treated with cultured ECs. Scar quality impacts patients’ lives in many ways due to cosmetic and functional concerns.

Additionally, there is a high economic burden on patients due to extended hospital stays and the cost of rehabilitation and reconstructive therapies. Because of this, additional research in burn wound treatment and the improvement of scar quality will always be of the highest priority.

It was revealed that epithelial cells applied to a carrier system could, in fact, reduce wound healing time and improve both short-term and long-term functional as well as cosmetic scar quality.

It was observed that the primary outcome was wound closure after five to seven days, said the researchers. Secondary outcomes were safety and scar quality, which were measured at three and 12 months.

Read more on: http://ingentaconnect.com/content/cog/ct/pre-prints/content-CT-1380_Gardien_et_al

Have Researchers Found the Best Method of Harvesting Autologous Fat?

A study published in the Journal of the American Society of Plastic Surgeons sought to examine the method that will optimize the process of harvesting lipoaspirate before grafting.

Dr. Emily Cleveland, together with her colleagues from the New York University Institute of Reconstructive Plastic Surgery, examined various articles on the methods of processing human fat for autologous grafting in an evidence-based review.

They found that there was no single viable method that may be advocated as the best technique for lipoaspirate process.

Autologous fat harvested through liposuction techniques is used by both cosmetic and reconstructive surgeons. As a filler, it has several advantages including availability, biocompatibilty, ease of harvest without risk of allergic reaction or rejection, and it's inexpensive.

This technique has been used in several procedures including, but not limited to, facial rejuvenation, breast augmentation and reconstruction, treatment of congenital anomalies, and improvement of soft-tissue damage due to radiation therapy.

Despite its advantages, the autologous fat transfer technique is also wrought with setbacks. Viability and the retention of fat graft cannot be predicted with certainty because of lack of clear data pinpointing factors which may be responsible for the variability in results.

However, there is a wide belief among practitioners that the lack of standardized procedure, especially with that of postharvest fat processing, significantly contributes to the variability. Currently, several techniques of fat harvest before transplantation are used.

Among them are the use of simple decantation, cotton gauze rolling, centrifugation, and washing in physiologic solutions.

In the study, randomized controlled trials, clinical trials, and comparative studies comparing at least two of the following techniques were included: decanting, cotton gauze (Telfa) rolling, centrifugation, washing, filtration, and stromal vascular fraction isolation.

Results of the study were as follows:

• There is a lack of superior method for processing harvested lipoaspirate.
• Simple decantation has previously been demonstrated to preserve a large number of intact and nucleated adipocytes. However, it allows a significantly greater amount of aqueous and lipid contaminants to remain in the specimen, particularly hematogenous cells and other materials that are believed to be proinflammatory and thus harmful to graft survival. Recent publications further confirm this, demonstrating lower rates of decanted graft viability relative to centrifuged and washed specimens.
• There are limited data to suggest that cotton gauze rolling of the lipoaspirate produces a graft largely free of contaminants, with superior in vitro adipose-derived mesenchymal stem cell content and high rates of in vivo retention but the technique is quite labor intensive.
• Centrifugation is perhaps the most widely used technique for postharvest fat processing, and has previously been considered the criterion standard. The most commonly used settings are those described by Coleman, in which lipoaspirate is spun at 1200 g (3000 rpm) for 3 minutes, followed by discarding the aqueous inferior layer and wicking off the free oil top layer. The middle adipose layer is then grafted. Some have suggested this may not be the most viable technique, in that it fails to incorporate the “pellet,” which contains the highest number of adipose-derived mesenchymal stem cells in the harvested specimen. Recent literature has demonstrated lower rates of graft viability after centrifugation relative to washing,although equivalent or superior results have been shown by some after “soft” centrifugation (400 g for 1 minute). Nevertheless, other research continues to support the equal effectiveness of standard centrifugation in preserving adipose-derived mesenchymal stem cells and producing viable in vivo grafts.
• Washing the lipoaspirate has previously been demonstrated to preserve both a large number of mesenchymal stem cells and a large number of adipocytes, thus satisfying both theories for graft survival. Several commercially available technologies that use washing techniques also appear promising for efficient, effective processing of lipoaspirate. This finding is somewhat confounded, however, by the use of multimodality technologies such as those used by Salinas et al. (washing then Telfa rolling or centrifugation), and processing with the Puregraft and Revolve systems, which first filter the lipoaspirate before washing. In addition, limited or no data are available to demonstrate in vivo superiority of these techniques.
•  Filtration methods appear to eliminate contaminants, and maintain viable adipocytes and a large portion of adipose-derived mesenchymal stem cells. This processing technique may be more efficient in producing viable graft material for large-volume fat transfers, which are becoming increasingly popular among both cosmetic and reconstructive surgeons. The Tissu-Trans Filtron inline filtration system holds promise, but there are to date only extremely limited data available to support its use.
• Similarly, there is only limited evidence to date to support the supplementation of processed lipoaspirate with additional stromal vascular fraction. Although viable isolation methods have been developed, a great deal of further research is required to determine whether this additional cost and effort is justified by superior clinical outcomes. The Celution 800/CRS System may be a viable method for isolating stromal vascular fraction in clinical settings for augmentation of autologous fat used for grafting; however, no subsequent in vivo study was performed to demonstrate its superiority relative to the other proprietary systems examined in this study. 

In conclusion, the authors said that they 

 did not find compelling evidence to advocate a single technique as the superior method for processing lipoaspirate in preparation for autologous fat grafting. A paucity of high-quality data continues to limit the clinician’s ability to determine the optimal method for purifying harvested adipose tissue. Novel automated technologies hold promise, particularly for large-volume fat grafting; however, extensive additional research is required to understand their true utility and efficiency in clinical settings.

More information about the study can be found at: http://journals.lww.com/plasreconsurg/Fulltext/2015/10000/Roll,_Spin,_Wash,_or_Filter__Processing_of.16.aspx?WT.mc_id=HPxADx20100319xMP

What's The Best Music For Face Lifts?

The next time you're performing a face lift, consider what music you're listening to.

A survey of surgeons in the UK revealed that a whooping 90% listen to music while they are operating on their patients; with half of respondents favoring up-tempo rock, 17% pop music and 11% classical.

In fact, an article written by Henley J, “Music for surgery,” published in The Guardian (2011) revealed that plastic surgeons play the most music. When asked, the surgeons revealed that music contributed to creating a "harmonious and calm atmosphere."

According to a 1994 publication of the Journal of the American Medical Association,

Surgeon-selected music was associated with reduced autonomic reactivity and improved performance of a stressful nonsurgical laboratory task in study participants.

Further, researchers from the psychology department at the State University of New York at Buffalo, found that listening to Pachelbel was better than not listening to any music at all. There was a decreased stress and increased performance after surgeons listened to music, especially when it was their own choice.

A recent study reveals that listening to music may reduce the time spent on surgical closures. The study was conducted with 15 residents performing layered closures on a simulated wound model on a pig's feet. These were done with and without their preferred music.

Twelve residents (five lower level and seven upper level residents) completed both sessions, performing 48 repairs. Blinded faculty completed 144 repair ratings.

These were the results of the pig's feet study:

• There was an 8% overall reduction of operative time among all residents.
•  There was a 10% decrease in the operative time of surgical closure for upper-level residents who were listening to their music of choice.
•  A resident took an average of 11.5 minutes to complete the surgery without music. On the other hand, it only took 10.6 minutes to complete the repairs with music. 

The study further revealed that there was also an improved efficiency and repair quality for those who listened to music.

For patients, music reduces anxiety before surgery. A research done by Yale University anaesthetist Zeev Kain reveals that music decreases the amount of pain or the patient's needs for anxiety medication. A study by the department of anaesthesia at Glasgow's Western Infirmary surveyed 200 anaesthetists; it found 72% worked in theatres where music was played regularly, and around 63% generally enjoyed it.

Some 26%, though, said they thought music, especially music they didn't know and like, could at times "reduce vigilance and impair communication".

On the other side...

It's a distraction. Junior surgeons who are performing new tasks may be distracted by operating room music. This was reported in a November 2008 issue of Surgical Endoscopy.

For patients, it may also be a cause for discord and anxiety, especially when the music is not to their liking. The results are ultimately related to the surgeon's preferences as to the kind of music and its volume.

It is important that both create a harmony in the operating room between and among the surgeons and the patients. The reduction in the amount of time to perform a surgery finds a positive welcome in the healthcare environment.

The September 2015 issue of the Aesthetic Surgery Journal says that

In the current health care environment, where cost reduction is center stage and operative time is money, every second counts.

Read more on:

http://www.theguardian.com/lifeandstyle/2011/sep/26/music-for-surgery http://cosmeticsurgerytimes.modernmedicine.com/cosmetic-surgery-times/news/music-improves-surgical-closures

Viability of Autologous Fat Calf Grafting

Research shows that autologous calf fat grafting is a viable alternative to traditional implant-based calf augmentation for congenital calf discrepancies and aesthetic pseudo-varus deformity.

According to the study published in the official publication of the American Society for Aesthetic Plastic Surgery (ASAPS), Aesthetic Surgery Journal, fat grafting for slender calves provides results that are comparable to those obtainable via traditional methods. 

Some patients who want to undergo calf implants are concerned with the risks associated with the surgery and the possibility that strenuous exercise may cause the implant to move. Some plastic surgeons use silicone implants that is selected based on the patient's anatomy. These implants are placed under the fascia of the original calf muscle that is strong enough to withstand physical sporting activities.

Researchers Gerhard S. Mundinger and James E. Vogel pointed out in the research that there are few studies published regarding the advantages of fat grafting for calf augmentation and re-shaping compared with the traditional silicone calf implants.

According to Dr. James E. Vogel,

Autologous fat augmentation offers a number of advantages over calf implants, including liposuction in adjacent areas to improve calf contour, smaller incisions, additional augmentation through subsequent fat grafting, durable results, lack of foreign body reaction, and precise patient-specific adjustments not possible with off-the-shelf implants.

Medial and lateral calf augmentation was accomplished with injection of prepared autologous lipoaspirate intramuscularly and subcutaneously.

Thirteen patients underwent calf augmentation and reshaping with autologous fat grafting over a period of five years. Ten patients underwent bilateral calf augmentation, and three cases were performed for congenital leg discrepancies.

Prior to the fat transfer, local anesthesia was injected to utilize the smallest amount of effective anesthetic volume. This was also done to precisely place it into the muscle resulting in less sedation and more rapid postoperative recovery.

Fat was harvested from the abdomen, lateral thigh, medial thigh, waistline, flanks, axilla, upper back, and hips. Irrespective of the fat harvest site, liposuction was also performed at the knee to improve contour.

A mean of 157 cc of separated fat was transferred per leg, with roughly 60% and 40% transferred into the medial and lateral calf, respectively. Injections were first performed directly into the calf muscles and then into the subcutaneous calf tissue.

Four patients underwent a second round of autologous fat injection for further calf augmentation because they desired additional volume. Fat volume was judged to be sufficient when the calf was minimally firm but not tense. At a mean of 19.6 months of follow-up, durable augmentation in calf contour was documented by comparison of standardized preoperative and postoperative photographs.

The research concluded that the use of autologous fat transfer is a viable option compared to the use of traditional silicone implants.

Read more on: http://asj.oxfordjournals.org/content/early/2015/09/01/asj.sjv166

Search for the Best Hyaluronic Acid Filler

The October issue of the official medical journal of the American Society of Plastic Surgeons (ASPS) reports a new and validated method for providing standard cohesivity ratings for hyaluronic acid dermal fillers.

The search for the best hyaluronic filler comes after the surge of interest in the use of dermal fillers to enhance shallow contours, soften facial creases and wrinkles and improve the appearance of recessed scars.

Dermal fillers can be very helpful in those with early signs of aging, or as a value-added part of facial rejuvenation surgery. These fillers are often injected in medspas or a surgeon's office and are predictable, with relatively minimal risks and side effects.

In 2014, ASPS data revealed that around 2.3 million dermal filler injections were done. Statistics from the Cosmetic Surgery National Data Bank and other market research show that dermal filler market in the United States is valued at a whooping $1 billion.

Hyaluronic acid dermal fillers are natural, gel-based products which are highly compatible with the body, making them the most commonly used dermal filler in the industry. Plastic surgeons are now looking for evidences that will aid them in selecting the product that will give the best result for their patients.

Though there is a wide range of available products, there still exists a lack of scientific data to support the rheologic or the flow-related properties of the available dermal fillers in the market.

Dr. Hema Sundaram, a dermatologist in Rockville, MD, Samuel Gavard Molliard, a scientist in Geneva, Switzerland, and colleagues used the ratings of cohesivity and other biophysical properties to identify the dermal filler that is suited to each procedure being done.

The biophysical characteristics of hyaluronic acid gel fillers reflect individual manufacturing processes. They confer rheologic properties that provide scientific rationale with Evidence Level II clinical correlation for selection of appropriate fillers for specific clinical applications.

Cohesivity measures the capacity of a material to "stick together" and not dissociate. It is a key property that maintains gel integrity, contributes to tissue support with natural contours, and diminishes surface irregularities.

Researchers point out that products with higher cohesivity scores are not always the best. The ranking system aims to ‘provide a scientific rationale for the intuitive selection of different products for specific clinical objectives.’

According to Dr. Sundaram and colleagues, fillers with higher cohesivity may be better used for more superficial placement, or placement in mobile areas such as around the mouth or eyes while products with lower cohesivity may be effective for use as ‘deep volumizers’.

The researchers developed a standard test for comparing the cohesivity of hyaluronic acid dermal fillers. Samples of each filler gel were dyed, then squeezed into water and stirred using automated technology.

A panel of plastic surgeon and dermatologist specialists experienced in using HA fillers then rated each sample’s cohesivity on an original five-point scale, known as the Gavard-Sundaram scale.

Cohesivity scores of the FDA-approved fillers varied across the full range of the scale: from ‘fully dispersed’ to ‘fully cohesive’. Cohesivity was rated high for one product, medium to high for three, low to medium for one, and low for one.

Aside from the data on cohesivity, researchers believe that comparative data on other rheologic properties (such as elasticity and viscosity) can make dermal filler procedures more sophisticated and successful.

----

Results of the study "Cohesivity of Hyaluronic Acid Fillers: Development and Clinical Implications of a Novel Assay, Pilot Validation with a Five-Point Grading Scale, and Evaluation of Six U.S. Food and Drug Administration–Approved Fillers" may be read on: http://journals.lww.com/plasreconsurg/Fulltext/2015/10000/Cohesivity_of_Hyaluronic_Acid_Fillers__.11.aspx

Domino Effect of Weight Loss Aesthetic Surgeries

New data released by the American Society of Plastic Surgeons (ASPS) revealed that US weight loss surgeries have spurred the number other procedures such as tummy tucks, breast lifts and upper arm lifts over the last four years.

In 2013, 179,000 Americans underwent weight loss surgery, averaging nearly 500 procedures every day. Reports from the American Society of Metabolic and Bariatric Surgery reveal that it's the most since 2009 and the third highest number on record. From then on, there has also been an across the board increase of plastic surgeries related to weight loss.

ASPS President Scot Glasberg, MD thinks that there is a correlation between the two types of procedures and this trend is expected to continue. According to him, post-massive weight loss patients are the number one growth area that he has seen in his practice, and he is also sure that's the case in many doctor's offices across the country.

"You can't attribute that to anything other than the fact that there are more massive weight loss patients out there looking to take care of the problems that they now have after their weight loss surgery. On the one hand they are thrilled to have lost so much weight, but they are trading one dilemma for another."

"Going forward, we'd like to be a part of the process from the outset, when patients are first starting to consider weight loss surgery. A lot of times patients think weight loss surgery is the answer to their issues, when in reality it may only be one step in the process."

Those who experience massive weight loss are often left with excessive amounts of sagging skin, particularly in the thighs, under the arms, around the abdomen and in the breasts. The excess skin can not only be unsightly and uncomfortable, in many cases it can be painful. with these, previously obese patients opt to have a plastic surgery to remove inelastic excess skin and tissue after substantial weight loss and to reshape or recontour their bodies.

In 2014, nearly 45,000 patients who experienced massive weight loss also opted to undergo plastic surgery to reshape their bodies. While those numbers represent the biggest single-year increase in nearly a half decade, it's still only a fraction of patients who may benefit from it.

Henry Ford Hospital researchers report that aesthetic procedures following bariatric surgeries may contribute to improving their long-term results. The researchers recorded patients' Body Mass Index both before the bariatric surgery and 2.5 years after the procedure. Out of the patients who had a contouring surgery, the average decrease in BMI was 18.24 at 2.5 years. This is in comparison to statistically significant decrease in BMI of only 12.45 at 2.5 years for those who did not have further surgery.

Dr. Jason Lichten, MD, of Lancaster, Ohio says that "If plastic surgeons can get involved with patients earlier, we can not only give them a more realistic idea of what to expect from a physical standpoint, but we can help them devise a plan for any follow up procedures after their weight loss.

Read more:

http://www.plasticsurgery.org/news/2015/massive-weight-loss-fuels-surge-in-plastic-surgery.html

Scar Management Techniques for Surgeons

Each year, it is estimated that around 100 million people in developed countries acquire scars after undergoing elective surgery and surgery for trauma. In a purely cosmetic surgical procedure such as an aesthetic breast surgery, scarring is viewed as a source of dissatisfaction among patients.

Prevention and treatment of unaesthetic scar formation after an operation greatly rests on plastic surgeons who perform these operations. Scarring may have several unpleasant aesthetic and psychological consequences to the patients including diminished self esteem, stigmatization, anxiety and depression.

In a study published at Journal of Plastic, Reconstructive & Aesthetic Surgery, an international, multidisciplinary group of 24 experts developed a set of practical, evidence-based guidelines for the management of linear, hypertrophic and keloid scars which could be useful for surgeons, dermatologists, general practitioners and other physicians involved in the prevention and the treatment of scars.

Here are some of the results:

1. After a surgery, prevention of abnormal scar formation should be a priority. In an elective surgery, the position and length of scar is to be greatly considered. As much as possible, the incision should be parallel to the relaxed skin tension lines. During the operation, the surgeon should ensure that excessive tension on the wound edges is avoided. Several measures may also be done to reduce inflammation, provide rapid wound closure, reduce the risk of infection, and provide an early surgical wound coverage.

2. Following a wound closure, scar prevention consists of three phases: tension relief, hydration/taping/occlusion, and pressure garments. Recent studies show that offloading mechanical forces using a stress-shielding device made from silicone polymer sheets and pressure-sensitive adhesive significantly reduced scar formation. Also, the use of botulinum toxin A decreases tensile forces on post-surgical scars and results in significant improvements in the cosmetic appearances of scars compared with placebo injections.

3. Silicone products may help to prevent excessive scar formation by restoring the water barrier through occlusion and hydration of the stratum corneum and need to be used as soon as the wound/suture is healed. Moisturizing emollient and humectant creams and moisture-retentive dressings such as silicone sheets and fluid silicone gel have been shown to be beneficial for itching scars, and can also reduce the size and pain or discomfort associated with scars as well as improving their appearance.

4. Randomized studies in animals and humans have shown that ultraviolet radiation increases scar pigmentation and worsens their clinical appearance. A preventive measure of avoiding exposure to sunlight and the continued use of sunscreens with a high to maximum sun protection factor (>50) until the scar has matured is recommended.

5. For patients with linear hypertrophic scars who have further scar maturation after 6 months, silicone therapy should be continued for as long as necessary. For those with an ongoing hypertrophy, more invasive measures are indicated such as the use of intralesional corticosteroids. This is the only invasive management option which currently has enough supporting evidence to be recommended in evidence-based guidelines.

Additional injectable treatment options which may help to treat hypertrophic scars (and keloids) include bleomycin, 5-fluorouracil and verapamil, although the evidence to support these is currently more limited than for intralesional corticosteroids. If the patient develops a permanent (>1 year) hypertrophic scar, surgical scar revision may be considered.

Pressure therapy has recently been considered as an ‘evidence-based’ modality for the treatment of scars. The mechanism of its action remains poorly understood despite its widespread use around the world. Part of the effect of pressure could involve reduction of oxygen tension in the wound through occlusion of small blood vessels resulting in a decrease of (myo)fibroblast proliferation and collagen synthesis. Pressure therapy can also provide symptomatic treatment benefits such as the alleviation of oedema, itchiness and pain which may contribute to the patient's well-being.

Laser therapy is another invasive option which can be used to treat the surface texture of abnormal scars and may also be suitable for the treatment of residual redness, telangiectasias or hyperpigmentation. This has also been advocated for the prevention or minimization of both post-surgical and traumatic scars, and even in combination with botulinum toxin. An increasing number of articles being published on the successful management of hypertrophic scars with lasers is increasing the interest in this therapeutic modality.

6. Keloids are also best treated in centres with specialized expertise. Patients with growing minor or major keloids should first be treated with silicones in combination with pressure therapy and intralesional injections of corticosteroids. Some experts recommend that the lateral parts of keloids should not be excised, but should be joined together and left in situ. However, others have objected to this proposal and consider that the cells from these lateral parts of the keloid are more active in terms of collagen production.

Both electron beam irradiation and brachytherapy with iridium 192 can be used after surgical removal of the keloid to reduce recurrence rates. Objections were raised because of the potential risk of inducing malignancy but a study conducted has concluded that the risk of malignancy attributable to keloid radiation therapy is minimal.

Cryotherapy may also be used as an invasive treatment modality for keloids. In a study of 10 patients, scar volume was significantly reduced by 54% after one intralesional treatment with no recurrence over an 18-month follow-up period.

7. Silicone therapy is advocated as a non-invasive first-line prophylactic and treatment option for both hypertrophic scars and keloids. For non-invasive scar management options. silicone sheets and silicone gels are universally considered as the gold standard in scar management and the only non-invasive preventive and therapeutic measure for which there is enough supporting data to make evidence-based recommendations.

Silicone therapy is easy to use and is associated with only minimal side effects such as pruritus, contact dermatitis and dry skin. This therapy is believed to prevent and treat scars through occlusion and subsequent hydration of the scar tissue. Several clinical studies have indicated the beneficial effects of silicone gels in the prevention and treatment of scars. Several comparative studies with silicone sheets have shown that fluid silicone gels have at least equivalent efficacy although patients may find the gel formulations easier to use.

Scars may leave several psychological impacts on patients after their surgery. It is important that appropriate scar management measures are done and tailored to the needs of the individual patient and wound requirement. Preventive measures should be prioritized and applied before, during, and after wound closure.

For more details, you may visit:

http://www.jprasurg.com/article/S1748-6815(14)00173-9/fulltext

Hyaluronic Acid for Facial Paralysis

Lip filler hyaluronic acid may be useful for people with facial paralysis.

In an interesting use case for the fillers in use at every cosmetic clinic,... A small research study conducted at the Johns Hopkins and Stanford universities reveal that aside from hyaluronic acid's use in cosmetic surgery, it may be useful for patients who struggle with drooling, eating, and drinking because of lack of lip control due to facial paralysis.

According to Kofi Boahene, M.D., a facial plastic and reconstructive surgeon in the Department of Otolaryngology-Head and Neck Surgery at the Johns Hopkins University School of Medicine, facial paralysis causes both both physical and psychological problems among patients making them self-conscious about how they look.

Boahane has used the analogy of a plant filling its leaves and stems with water to maintain structure. He says that

It’s a crude analogy, but injecting the lips with hyaluronic acid works in much the same way. It tones the tissue surrounding the muscle.

Boahene was working on a patient with then-undiagnosed case of muscular dystrophy when he had his own eureka moment. He stumbled across a possible role for hyaluronic acid injection to improve a patient's lip muscle tone. After trying the injection, the patient's face appeared stronger and her articulation improved.

Boahene and his collaborators tested 22 more patients with facial paralysis. His team got the participants' baseline measure of lip tone and the weakest points were identified by having them blow air with pursed lips. The researchers injected hyaluronic acid at the point where the air escaped.

After the procedure, he said that the patients showed marked improvement as confirmed by a speech therapist who conducted the assessment. Boahene further adds that the injection may last up to a year when done for cosmetic improvement.

Because lip augmentation and injection is a minimally invasive procedure, a plastic surgeon or dermatologist may perform such procedures. However, Boahene mentions that it is advised that the lip injectionsbe done by physicians who are experienced with treating muscle weaknesses and facial paralysis.

Read more on:

http://ictr.johnshopkins.edu/news_announce/cosmetic-surgery-drug-to-treat-facial-paralysis/

Avoid Medspa Litigation Claims = Provide Comprehensive Information

Exceptional patient services will do more than just keep your patients happy, they'll also keep you out of court (or may your stay much shorter).

In a recently decided case of James v. Decorato, the defendant medical practitioner was absolved of liability after showing to the court the the patient has been adequately informed about the procedure that she will be undergoing.

Their case stemmed when the patient and plaintiff Rebecca B. James sued the defendants John W. Decorato, M.D. and Aesthetic Pavilion, LLC for alleged negligence and malpractice by the latter. In her complaint, Rebecca claimed there was negligence in the performance of various cosmetic surgeries which included liposuction, blepharoplasty, lipoplasty, autologous gluteal augmentation with fat grafting, submental and neck smartlipo, bilateral transconjunctival lower blepharoplasty with CO2 laser resurfacing, and autologous upper and lower lip augmentation with fat grafting.

She alleged that there the malpractice resulted in the formation of excessive and severe scarring, non-uniform appearance of her abdomen, concave left inner thigh with pain, hypo-pigmented skin under eyes leaving non-uniform skin color on the face, among others.

Further, she said that Dr. Decorato violated the Public Health Law when he allegedly failed to disclose alternatives, risks and benefits that may arise after the treatment. She said that had she known of them, she would not have undergone with the treatments altogether.

In an answer, Dr. Decorato said that the plaintiff was able to sign multiple consent forms which outlined the risks and effects that may happen after the treatment. The defendant doctor also argued that the plaintiff's argument must be summarily dismissed because they only stemmed out of her dissatisfaction with the results of the procedures.

In support, Dr. Decorato submitted to the court the examination done by Dr. Theodore Diktaban, a certified Plastic, Reconstructive as well as Head and Neck Surgeon. Dr. Diktaban indicated that he was able to review the consent forms signed by the plaintiff and found them all clear and complete.

According to Dr. Diktaban's affidavit,

The forms adequately provided for the proposed procedures, alternatives thereto, and the reasonably foreseeable risks and benefits associated therewith, including the need for revisionary surgery. The lack of an informed consent could not be a proximate cause of any of plaintiff's subjective dissatisfaction, which she classifies as injuries. Regarding the issue on malpractice and negligence, the pre-and post-operative care rendered to plaintiff comports with good and accepted medical practice.

He further opined that the results of plaintiff's surgery were devoid of any functional deficits, except for the purported and subjective paresthesias of the left medial thigh.

These claims were opposed by the plaintiff Rebecca and presented the statement of a cosmetic surgeon, Dr. Richard Marfuggi. He claimed that after examining Rebecca, he can say that "with a reasonable degree of medical probability, the complications experienced by plaintiff were the result of Dr. Decorato's failure to follow good and accepted practice".

According to the Supreme Court, the basis for establishing the liability of the physician is the departure of the physician from accepted community standards of practice and this was the proximate or direct cause of the plaintiff's injuries.

The Supreme Court sided with Dr. Decorato and summarily dismissed the case. Dr. Decorato, with the affirmation of the statement of Dr. Diktaban, was able to show that indeed he did not deviate from accepted medical procedures. The Supreme Court noted that the plaintiff's claim of "lack of informed consent" has not been proven. Instead, Dr. Decorato was able to produce in evidence the fact that Rebecca was able to sign the consent forms.

On the other hand, the plaintiff Rebecca and Dr. Marfuggi's affidavits did not show any medical evidence establishing that Dr. Decorato was indeed negligent. According to the Supreme Court, Dr. Marfuggi's recitation of facts failed to address the concern of whether or not this was a departure from accepted practices.

Note to self: make sure that all forms are clear and complete.

Getting Naked on the Internet: What does the law say?

Telemedicine and Cyber Security

The Health Information Portability and Accountability Act (HIPAA) is a federal law that protects the privacy of your personal health information (PHI). HIPAA includes several rules and provisions that set guidelines and requirements for the administration and enforcement of HIPAA. The relevant ones for the exchange of PHI in the digital cyberspace are the Privacy Rule1, the Security Rule2, and the aptly named Health Information Technology for Economic and Clinical Health (HITECH) Act3.

Telemedicine is a burgeoning field of medicine that incorporates digital technology such as electronic health records (EHR), information sharing, and videoconferencing to enhance the interaction between physicians and their patients, and ultimately, improve the delivery of healthcare. Having been a plastic surgeon for several years now, I’m all too familiar with meeting people at social events, and immediately getting bombarded with intrusive and unusual questions and requests as soon as my chosen profession is ousted. Sure, it’s unlikely that a woman will disrobe and expose herself in front of me and my wife at a friend’s dinner party, but get us into an online “private” videoconference call, and who knows what body parts will make an abrupt entrance into the conversation. Physicians must approach with caution, says American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) President Stephen S. Park, M.D. in a recent article4. But, for me and most physicians I know, I feel like the cat is already out of the bag. Considering the amount of texts, emails, online chats, phone conversations over internet and satellite lines, and selfies of both pre- and post-op patients I’ve been privy to, I’m sure I’ve already broken too many laws, and completely disregarded the good doctor’s advice. The truth is, though, that we’ve only begun to scratch the surface.

Telemedicine may involve the electronic exchange of PHI which is protected under HIPAA law. Security considerations with telemedicine involve making sure unauthorized third parties cannot eavesdrop on or record a videoconferencing session where sensitive PHI is transmitted seamlessly, and unfortunately, innocently. Recently, a monumental data breach at one of the nation’s largest insurance providers has spurred a bipartisan political effort to reexamine HIPAA as it relates to telemedicine, possibly adding costly and cumbersome requirements to encrypt EHR data5. Additionally, a recent report done by BitSight Technologies, a cyber security risk analysis and management firm, found that healthcare and pharmaceutical companies ranked the lowest among the four industry categories studied6. Suffice it to say, people are taking heed of this emerging new threat.

The aforementioned laws, rules, and regulations guide the generation, maintenance, and implementation of telemedicine HIPAA compliance. We must be cautioned, though, that HIPAA compliance does not necessarily equate to actual cyber security, and that simply meeting standards set forth in these regulations may not be enough. As more public attention and scrutiny rise to the forefront of media exposure, look for the healthcare industry to take the cyber security threat much more seriously.

Daniel Kaufman, MD
Discreet Plastic Surgery

Bibliography
1. http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/
2. http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/
3. http://www.healthit.gov/policy-researchers-implementers/health-it-legislation-and-regulations
4. http://cosmeticsurgerytimes.modernmedicine.com/cosmetic-surgery-times/news/cosmetic-virtual-consult
5. http://medicaleconomics.modernmedicine.com/medical-economics/news/senate-review-hipaa-security-medical-records-light-anthem-breach
6. http://info.bitsighttech.com/bitsight-insights-industry-security-ratings-vol-4-rc

Plastic Surgeries for Men... Again

Recent trends in cosmetic surgery reveal that more and more men are requesting for aesthetic surgery. This may be attributed to men wanting to feel good and not wanting their female counterparts to look better than they do after the latter has gone to some rejuvenation procedures.

Nowadays, more men are looking forward to having a more balanced nose, a rejuvenated face and a trimmer waistline. There are those working dads in their late 40s who thinks to themselves that he used to look so goon in college. In a Business Insider, it was mentioned that these "athletic dads" tend to avail of jawline recontouring, liposuction, and a small eyelift.

According to American Society of Plastic Surgeons member Dr. Jay Lucas, MD, some of the most common procedures are eyelid rejuvenation, neck lifts, rhinoplasty, chin augmentation, and male breast reduction.

Eyelid Rejuvenation

Signs of aging are often shown in the eyes. Fortunately, surgery to restore the upper eyelids to a fresh and vibrant appearance with correction of any eyelid droop can be a good remedy. The lower lids can be rejuvenated by removing excess fat and repositioning this tissue over the cheek to eliminate the tear trough. This can be important not only in social situations, but also in how a person is viewed in the workplace.

Neck Lifts

Neck lifts help men get rid of the hanging skin and excess fat around his neck which obscures his jaw line and shows his signs of aging. This procedure helps men restore their youthful look to create a strong jaw line and a crisp chin-neck junction. Neck lifts are done as an out-patient procedure with minimal pain and a recovery of around two weeks.

Rhinoplasty and Chin Augmentation

These procedures suggest proportionality in the face of the patient and requires a great understanding of the patient's facial appearance. If the nose seems big, maybe the lower face is out of place, such as a small lower jaw or chin. To create a harmonious facial appearance, rhinoplasty along with chin augmentation is performed.

Liposuction

This is not a weight loss technique, rather it is a contouring tool which reshapes the abdominal area to create a sleeker frame. Male patients are however encouraged to go on a healthy diet and exercise before availing of this procedure as an adjunct to improve appearance.

In our culture, looking good and youthful is prized, men included. The advent of the advent of latest technology and availability of several plastic surgery procedures drive men to look and feel good themselves. Med Spa owners may capitalize on this trend to open their clinics not only to the women, but the men clientèle as well.

Read more on: http://www.plasticsurgery.org/news/plastic-surgery-blog/most-commonly-requested-plastic-surgery-for-men.html

Buyer's Remorse In Plastic Surgery

"OMG!! what did I do?! ...

I must be crazy to do this!" said my patient only hours after her tummy tuck. She was in some pain and distress, as the anesthesia was wearing off, and began a tirade of self-disparaging statements reflecting all her worst fears and anxieties about the surgery.

I stopped what I was doing, and sat down with her on the recovery room bed to calm her down. It's amazing how comfortable those recovery room beds are...and the patients seem to really like it when I take my time to explain and review things with them. She did fine after some pain meds and a little small talk, and on her 1 week postop visit, was happy as a clam with her new flat tummy. And that's when I realized just how common "buyer's remorse" is in plastic surgery.

Plastic surgery, especially cosmetic surgery, is elective. That means that it isn't surgery that you need, but surgery that you want. Oftentimes, people overlook the pain and discomfort that is inherent to any surgery. Although, most people who have had plastic surgery, and, gladly, the vast majority of my patients, will say that they are happy with the decisions that they made, a certain segment of the patient population will always have difficulties in adjusting to the postoperative demands, no matter how carefully they were selected by the surgeon or how well surgery was performed.

Every plastic surgeon hones his/her patient selection skills over years of education, training, and practice. The goal of every plastic surgery practice is to only have happy patients. As this is an ideal that will probably never be reached, we surgeons must realize that some of our patients will be unhappy, at various stages of the postoperative period. Those patients need special attention, understanding, and a compassionate review of clinical details. They must be empowered, and be actively involved in the procedures of postoperative recovery. It's also important to give your patients options as to colleagues who may serve as second opinions.

As a patient, if you find yourself unhappy with the results of a cosmetic procedure, take a deep breath and fret not, as it depends on the timing. Most early remorse cases are due to the unexpected, and probably poorly managed, pain and discomfort. Moreover, remorse is clearly correlated with incidence of complications of surgery. In the case of the former, simple and more precise pain control and behavior modification is all that is needed. In the latter, both preoperative and postoperative miscommunication between patient and surgeon is the usual contributing factor. As difficult as it is to do, as a patient you must communicate with your surgeon, even if you believe that he/she is responsible for a poor outcome.

We must realize that we can all end up being the patient who regrets having plastic surgery. It can happen if you're the best patient, or if you have the best doctor. What's important for both of you is to keep the lines of communication open so that proper, just, and adequate resolution is reached. No patient should abandon his/her doctor, and the opposite is just as true.