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

FDA Approved Saline-filled Breast Implants

Ideal Implant Incorporated has recently announced the FDA approval of its Structured Breast Implant for use in the United States and Canada.

The breast implant was designed by a plastic surgeon and it is the first to provide women with the feel of silicone gel-filled implants combined with the safety of only saline inside. The natural feel of the breast implant is attributed to its patented unique design and internal structure which was a product of more than 10 years of research and clinical studies.

As to its design, the company's website provides the following:

Years of research and testing led to this innovative design, with a series of implant shells nested together and two separate chambers, which hold the saline filler. The internal structure controls movement of the saline, and is designed to reduce folding and wrinkling, thought to be the main cause of implant rupture and deflation. On the outside, the edges have been lowered for better contouring to the chest wall.

According to Robert Hamas, MD, a Dallas plastic surgeon:

Now, for the first time, women can have a breast implant that offers them a natural feel without silicone gel. It has only saline inside for their safety and peace of mind. Unlike silicone gel implants that have a high incidence of silent rupture that requires an MRI scan for detection, with the Ideal Implant, a women can look in the mirror each day and have the confidence of knowing her implants are intact.

In a study, patient satisfaction for those who received their first breast implants were at 94.3% while those who had replacements for their previous implants was at 90.6%. The high satisfaction rating among women were attributed to the natural feel of the implants coupled with ease of mind because of its saline-filled components. The surgeon satisfaction was also high at 95.9% for primary implants and 91.7% for replacements.

For more info,

you may visit www.idealimplant.com

or contact Adeena Fried, 917-633-4380, idealimplant@evolvemkd.com

How Patients Deal with Discomfort after CoolSculpting

Popsicle panniculitis became the inspiration for the non-surgical CoolSculpting procedure. This phenomenon was observed when excessive exposure to cold popsicles result in the reduction of fats in cheeks.

CoolSculpting usually works on patients who have fats in certain areas of their body that can be "pinched" by doctors. This procedure will not work with obese patients. It specifically targets fat cells and doesn't harm any muscle tissue or skin.

Patients undergoing this procedure often complain of discomfort, most often in the abdomen area, after the non-surgical treatment. Itching is associated with the body digesting the dead fat cells. A patient who has experienced such itchiness after the CoolSculpting noted that the doctor prescribed Neurontin to ease the discomfort felt while the nerves in the affected area are still recovering. Others also use compression garments or lightly massage the area to lessen the itch. Redness, bruising, and swelling may also develop for some patients but these are only temporary.

One patient took Motrin every five hours to treat the pain and inflammation in the area. With CoolSculpting, patients' level of discomfort is lower compared to those performed after a tummy tuck or liposuction. There are even patients who immediately go back to work the day after the non-surgical treatment, claiming that the discomfort they feel is tolerable.

Most patients are actually looking forward to the results and wouldn't mind the little discomfort. It is very important for those who administer CoolSculpting procedures to assess whether a patient can have this treatment. Also, they must be briefed and informed about the after-effects of the procedure and the discomforts they might feel.

Popsicle Panniculitis?

"Popsicle Panniculitis" can be caused by a number of conditions, most often exposure to cold that affects some infants 6 to 72 hours after they suck on a popsicle or ice cube. Popsicle panniculitis causes swelling and redness in the cheeks near the corners of the mouth. It's a rare condition that usually only affects infants and young children, possibly because infants have a higher concentration of fatty acids in their subcutaneous tissue than adults do. The only treatment required for popsicle panniculitis is to remove the source of cold or limit the child's exposure to cold.

Carboxytherapy- the CDT Evolution System

After performing Carbon Dioxide Therapy CDT for a long time with different technologies, I discovered that there are huge technology-dependent differences in the treatment itself. Since I tried out a new machine recently, I wanted to share my thoughts on one of them here.

Carboxytherapy is a treatment that takes its origins from 'spa medicine' in the 1920s. In 1932 injections of medical CO2 were put into practice and the studies demonstrated a good effect on patients suffering from arterial problems. Collateral signs of improving cutaneous aspects during the treatment encouraged the University of Siena, Faculty of Medicine to develop specific research. It has been possible to verify Carboxytherapy effectiveness in subcutaneous application with an adequate methodology and medical system for the improvement of local blood flow, the reduction of local adiposity, the increase of the dermis thickness, elasticity and quality as well as the reduction of skin irregularities (such as associated with liposuction and other body contouring techniques).

Carbon Dioxide Therapy (CDT) consists of injection into the sub-cutaneous tissue of medical carbonic CO2 with a small 30 G needle. The CO2 injection system with a needle linked to a tube is single use and the gas is medical and sterile. Even thought this method does not need any anaesthesia and is minimally invasive, the treatment must be realized by a medical practitioner who can follow up the patient. The treatment is secure and non– toxic. CO2 is naturally produced by cells as a by-product of metabolism. It is transported in the blood and exhaled through the lungs.  (Medical CO2 gas is used for laparoscopy surgical procedures.) Using a certified medical systems (such as CDT Evolution) there are no risks of air embolism, even if the CO2 gas is injected directly into a blood vessel.

The technology I worked with most recently is the CDT Evolution system (Carbossitherapia), an Italian system approved in the European Union (Law 93/42 CE0051 classeIIb). It is equipped with a mechanism pain control for the most sensitive patients who sometimes feel an annoying sensation during the injection of CO2 in the tissues. This pain control is what amazes me and my patients very much comparing this system to others: I can concentrate on my work rather than on pain management...

Read more about the CDT Evolution System here: http://www.carbossiterapia.it/prodotti.php

Aesthetic Predictions for 2010

I think everyone staring out in the aesthetic industry, especially if you are a non-core practice, needs some sort of a guru. Someone to guide you along the way in your decisions on equipment, procedures, pricing, staffing, standard operating procedures, menu of services, etc. Our guru many years ago was Fran Acunzo from Acara Partners. Perhaps Fran's most famous, or successful client, is Dr. Bruce Katz of Juva MediSpa in New York City.

I remember listening to some of his suggestions he had for us at the time and saying "Is he serious? I have no idea what this SmartLipo thing is, but if he thinks it is going to be the next big thing, then we had better trust him as our consultant". Needless to say, Fran was right. And not only about adding SmartLipo to our practice when it was first approved by the FDA, but other procedures and services as well. So, to me, when Fran speaks... I listen.

Fran blogged his predictions for aesthetic procedures for the year 2010 and it's already making it's way across the internet cited and adapted into blogs by SpaFinder.com (Read Susie's comments on such predictions) and many, many others. If you have not yet read his predictions, I'd like to post them here in their entirety:

Here are my 2010 top 10 predictions in the world of Aesthetic Medicine

1. Dysport will become a strong competitor to Botox.  Dysport, Medicis’ new entry into the world of botulinum toxin, was launched in the spring of 2009 and has begun to see increased demand as market awareness grows.

2. Non-invasive body contouring will continue to grow in popularity lead by Erchonia’s Zerona.

3. Face lifts will continue to drop in demand while liquid face-lifts grow in popularity, especially with the younger market (40 -54 year olds)

4. Fat transfer, specifically for natural breast enhancement, will become sought after by women who were previously uncomfortable with implants.

5. Laser Lipolysis will continue to be one of the most in-demand medical aesthetic procedures due to its minimal downtime and great results.

6. The younger audience (24 – 40 year olds) will continue to discover aesthetic medical services for preventive aging.

7. There will be an increase in the number of men having aesthetic medical procedures starting with facial fillers and injectables (i.e. Botox, Restylane, Radiesse, etc.)

8. The tipping point of when men and women want to have their tattoos removed will arrive and the demand will grow exponentially.

9. Facial Rejuvenation will come of age as medical practitioners perfect their skill combining aesthetic medical facial procedures for a complete Medical Makeover including the combination of fractional resurfacing, ablative resurfacing, chemical peels, photofacials, skin tightening, injectables and facial fillers, etc.

10. What was an Extreme Makeover in 2003 when the then popular TV show hit the airwaves will now become the Everyday Makeover.

It is entirely up to you whether or not you place your trust in Fran's predictions. I would guess to say there would be some discepancies amongst professions, but I can tell you I am already beginning to see many of these prove true in our own practice. It's also interesting to me that, upon research, I could find no other person or entity posting such predictions.

So, unless you have a crystal ball somewhere that has worked for you, I'm sticking to what has worked for us!

Author: Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course, Study Guide, and Advanced IPL & Laser Training course for medical estheticians and laser technicians.

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Laser Clinic Tatoo Removal

One of Medical Spa MDs eaders sent me this story on job hunters going to tatoo removal laser clinics in an effort to make them more employable.

The multi-billion dollar business of tattoo removal is enjoying some recession-proof growth — with one LA-based clinic even planning on going public next year to help fund a national expansion plan.

“More than 40 million people have tattoos and about seven million, or 17 percent, are in the process of figuring out how to get rid of them,” said John Keefe, the CEO of Dr. Tatoff, a California tattoo removal clinic, who hopes to use the proceeds from a 2010 initial public offering to grow to a 10-location chain.

“More than 66 percent of those tattooed are between the ages of 25 and 45 and what was cool to them at 18 is an eyesore now that they are a mother with kids,” says Keefe. The executive said revenue per client is about $1,600 — which comes out to $40 per square inch, per laser treatment  with an average of 10 treatments required. The average tattoo is four square inches, he said.

“It costs 10 times more to remove a tattoo than to put one on and it takes one year for safe and effective removal,” says Keefe.

The national market is currently fragmented, with dermatologists operating on a one-off basis and usually not dedicating their entire practice to tattoos removal.

The growing unemployment rate is also helping the company ink new business as job hunters feel the need to be competitive. Of course, many look to get rid of their tattoos because of personal taste — they may have simply fallen out of love with their tattoos or out of love with the name of the person indelibly inked on their arm.

I personaly never saw the attraction of getting into laser tatoo removal, but our patient population wasn't really inked-up either.

Is anyome meeting with real success with their tatoo laser removal services? Is tatoo removal cost effective? Is it dependant upon a certain inked demographic? What cosmetic lasers are being used to remove tatoos?

The Hidden Dangers of Beauty

Normally, I barely listen to the radio when driving in my car, but today on the John Tesh Radio Show (Sunday) my ears perked up when he started to discuss the hidden "dangers" of young girls using makeup too early. Dangers in makeup? Really?

The broadcast was entitled "The Ugly Truth About Young Girls Wearing Makeup". The line that grabbed my attention was "the sooner your daughter starts wearing makeup, the sooner it might kill her!" This was a quote coming from Stacy Malkan, a cosmetic expert who wrote the book Not Just A Pretty Face: The Ugly Side of the Beauty Industry. According to the John Tesh website, Malkan states "by the time most North American girls become teenagers, many have a daily make-up ritual that includes lipstick, mascara, eyeliner, nail polish and perfume, not to mention skin lotion, shampoo, conditioner, and hair color treatments." She goes on to say "in fact, experts estimate that a typical young girl now walks around with at least a dozen layers of beauty products on her body! As the makeup layers add up, so does her exposure to dangerous chemicals, and that’s very bad news for a young girl’s health."

Apparently the culprits are chronic exposure to parabens and phthalates which have been found to disrupt hormone levels during adolescent years which may result in early puberty. Malkin continues to state "one study found that HALF [sic] of all North American girls now begin to show signs of breast development by the age of 10 – which is more than two years sooner than females from our grandmother’s generation. Other studies link those unusual hormone levels to a higher depression rate among young girls, and a higher risk for breast cancer! That’s why experts recommend women of all ages find out exactly what chemicals go into their makeup."

There is a website suggested for reference to verify the ingredients in certain beauty products and cosmetics and it is called the Skin Deep Cosmetic Safety Database. I was instantly intrigued and raced to my Mac when I got home to give it a try! Here's how my products scored:

(Scale: 0-2=Low hazard; 3-6 Moderate Hazard; 7-10 High Hazard).

• Cleanser: 3 (moderate hazard) 
• Toner: 7 (high hazard) 
• Moisturizer: 5 (moderate hazard) 
• Eye Cream: 6 (moderate hazard) 
• Lip Cream: 7 (high hazard) 
• SPF 30: 7 (high hazard) 
• Concealer: 4 (moderate hazard) 
• Foundation Primer: 5 (moderate hazard) 
• Foundation: 9 (high hazard) 
• Loose Powder: 5 (moderate hazard) 
• Blush: 7 (high hazard) 
• Bronzing Powder: 8 (high hazard) 
• Eyeshadow: 7 (high hazard) 
• Mascara: 8 (high hazard) 
• Lipstick 6: (moderate hazard) 

My gosh, I'm a walking carcinogen!!! Like most women, I use an array of products, from medical grade like Obagi, spa grade like SkinCeuticals, high end department stores like Merle Norman, Estee' Lauder and Laura Mercier, right down to drug store brands like Maybelline. It seems no company's products were completely safe. And, makeup is just the beginning for young girls!

More and more young girls are taking their skin care regimens to the next level by having microdermabrasion treatments and chemical peels, with some escalating to laser and injectable therapies. Putting aside the various protocols for acneic adolescents, there has actually been a rise in the U.S. of young girls undergoing laser hair removal, photo facials, dermal filler procedures, even laser lipolysis. Where do we draw the line as clinicians? 21? 18? 16 with parental consent? I know in our medical spa we have been approached by parents inquiring as to what our policy is for treating adolescents for non-medical related conditions. The number one request is laser hair removal for ethic skin types predominately for excess facial hair. Many clinicians feel it is a low-risk procedure which can lift a child's self-esteem. Some clinicians disagree and feel a child is much too young to be exposed to laser therapies.

I'm not a laser expert and am uncertain as to if many aesthetic equipment manufacturers have performed clinical trials on adolescents for laser procedures (other than port wine stains). I'm more apt to believe the answer to this questions will become clearer as the years go on and by remembering the first rule is to "do no harm".

That, and to throw away your teenager's makeup!

Author: Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course, Study Guide, and Advanced IPL & Laser Training course for medical estheticians and laser technicians.

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LipoSonix: High Intensity Focused Ultrasound (HIFU) for your medspas body scuplting.

Tested on pigs with slow metabolism, LipoSonix wants to be the first to have a technology solution to liposuction. No word yet on if the test pits show impoved body image.

From the LipoSonix site: 

LipoSonix is taking a rigorous, science-based approach to technology development. All new clinical studies begin with the demonstration of patient safety and then progress to detailed efficacy studies that provide evidence for the aesthetic benefits of our device.

LipoSonix achieves targeted reduction of tissue volume by precisely focusing high intensity ultrasound energy to cause thermocoagulation of adipose tissue. A custom designed ultrasound transducer delivers energy across the skin surface at a relatively low intensity, but brings this energy to a sharp focus in the subcutaneous fat. At the skin surface, the intensity of the ultrasound energy is low enough so that no damage occurs. The focusing of the ultrasound beam at specific depths beneath the epidermis, combined with proprietary application techniques, results in adipose tissue thermocoagulation. This result is achieved through several mechanisms of action, including temperature rise secondary to direct absorption of ultrasonic energy and mechanical processes such as cavitation, streaming, and shear forces with their inherent thermal effects.

Once adipocytes have been disrupted, chemotactic signals activate the body's inflammatory response mechanisms. Macrophage cells are attracted to the area to engulf and transport the lipids and cell debris. This results in an overall reduction in local adipose tissue volume. The goal is to achieve precision that will result in effective non-invasive body sculpting.

LipoSonix' initial efforts involved extensive pre-clinical in vitro and in vivo testing to demonstrate proof of principle and refine specific treatment protocols. Initial human feasibility studies were performed on patients undergoing abdominoplasty surgery, allowing for detailed evaluation of the patho-physiological process. The safety of these trials was assessed through evaluation of extensive blood panels, gross pathology, histological analysis, and non-invasive imaging (including computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound.

Abstracts from Plastic Surgery 2005 (.pdf), 2006 (.pdf); the American Academy of Dermatology 2006 (.pdf); and the American Society for Aesthetic Plastic Surgery 2006 (.pdf)

(hat tip: Engadget , Medgadget, & Gizmag)

Anti-Aging: Skin, sundamage, & twins.

From Elle Magazine & Darrick E. Antell, MD

Though she has a sense of humor about it now—Block calls herself "the bad twin"—at the time, she was disturbed by the proof that years of excessive sun exposure had made her look so much older than her (formerly) identical sister.

Gay Block at 59 (left) with deep wrinkles and sagging skin. Her twin, Gwyn Sirota, spent less time in the sun, and it shows.

Rosacea? Melasma? Acne? Building community sites around medical conditions.

Self Organized Patient Communities

Patients with medical conditions often turn to each other for support. The web allows them to build a community no matter where they're located or how uncommon the condition.

Rosacea Patient Communities

• Rosacea Support Group
• Rosacea, Yahoo Health Group
• Rosacea News (a blog about Rosacea)
  

If you read these types of community posts you'll discover that there's a lot if information, but there are very few if any physicians participation in the discussion, even anonymously.

I read any number of sites each day where physicians are disseminating information, but not in these groups. Curious.

Botox for facial scars.

...an injection with botulinum toxin early after the occurrence of a wound = improved healing.

Stretch Marks May Predict Pelvic Risk

 Stretch Marks May Predict Pelvic Risk.

About half of all pregnant women get stretch marks, which often fade after delivery, according to the U.S. Department of Health and Human Services' National Women's Health Information Center.

The new study, published in The Journal of Investigative Dermatology, doesn't predict pelvic prolapse for every woman with stretch marks. But it does show twice as many women with pelvic prolapse also had stretch marks, compared with those without prolapse.