Wednesday, August 1, 2018

Cosmetic Surgery in Patients Taking Steroids

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Steroids refers to a broad group of chemicals produced by the body and drugs or medications with a spectrum of properties. All steroids have a common 4 ring chemical structure with side attachments that change its name and properties giving rise to everything from testosterone to bile, estrogen, estradiol, progesterone, prednisone, decadron etc. Most of these are found in nature produced by animals or plants but some can only be made synthetically in a lab. There are 2 main categories sex hormones and corticosteroids with subcategories that apply to each.

Categories (subcategories)Functional RegulationExamples
Sex hormones-androgens (anabolic steroids) and estrogenssex differences, puberty, reproduction, muscle and bone metabolism, fat metabolism and distributionTestosterone, Androstenedione, Estrogen, Progesterone, Estradiol, Medrogestone, Methylprednisolone
Corticosteroids
     Glucocorticoidssugar metabolism, immune function (reduce inflammation), healing, fetal development in the wombCortisol, Prednisone, Dexamethasone
     Mineralocorticoidsblood volume and pressure, kidney function, water balanceAldosterone, Fludrocortisone

Their relative category potencies and time length of effect vary. Dexamethasone's glucorticoid effect is 80 times stronger than cortisol, it lasts 6 times as long and has no mineralocorticoid effect. Testosterone is 5 times stronger than androstenedione. As the doseage or blood level increases each chemical begins to have effects in other categories so a high doseage of prednisone can start to cause water retention, a mineralocorticoid effect.

This blog post will focus on the glucorticoid portion of the above table. Glucocorticoids are commonly prescribed for allergies, asthma, a variety of skin conditions, ulcerative colitis, lupus, arthritis and many other different diseases as well as after transplant surgery. In the UK in 2008 0.79% of the population was prescribed long-term (i.e. ≥3 months) oral glucocorticoids. That is 484,270 people. In 2016 glucocorticoids were the 19th and 49th most common prescriptions in the US. In 2017 prednisone was the third most common prescription in the US.
brain adrenal axis
Glucocorticoid production by the body is regulated through feedback mechanisms via the brain (hypothalamus and pituitary gland) and the adrenal glands that varies with emotional states, sleep wake cycles, fasting vs. eating and activity levels. The brain stimulates the adrenal glands and high adrenal output reduces brain stimulation. The stress of surgery causes cortisol levels to rise within 45 minutes of skin incision, peak 5 to 10 times normal within 10 hours after surgery and fall back to normal within 24 hours if all goes well. The brain adrenal axis of control is primed to the equivalent of about 7.5mg prednisone per day stress free baseline. At lower levels the brain signals the adrenal glands to produce more. Therefore, medication doseages higher than this turn the axis off and make it less responsive or sensitive to stresses. At the extremes of low body production (Addison's disease) and high body production (Cushing's disease) there are easily visible body changes. In between those extremes the levels can still be such that response to surgery is impaired despite there being no visible physical indication before surgery because the brain adrenal control axis is impaired. This was first noted in the early 1950s in patients who had been taking glucocorticoid medications before surgery and collapsed after surgery with low blood pressure that normalized after the patients were given glucocorticoids. Thus there are 2 factors to consider, the baseline level of these chemicals in the bloodstream and the ability of the brain adrenal axis to respond to stress. The blood levels can be abnormal due to internal body causes such as adrenal failure or externally ingested or injected medications such as prednisone. Furthermore, different individual's bodies respond differently to the same doseage of these medications depending on the length of time of exposure. Once the brain adrenal axis has been exposed to the equivalent of about 7.5mg prednisone per day for as few as 5 to 7 days it takes up to a year without exposure to the medication for the adrenal portion of the axis to regain its sensitivity to brain stimulation. So even if the unstressed blood levels are normal within that time period the adrenal glands can't secrete more when stressed and can result in collapse. In such patients the recommendation is IV injection of 100mg of hydrocortisone (25mg of prednisone or 3 to 4mg dexamethasone) at the beginning of surgery. For minor surgery or imaging procedures with dye that should suffice. For more extensive surgery or complications following surgery the medication is given every 8 hours for 24 or more hours.

For safety in cosmetic surgery these patients have to be placed in 2 groups. The first is that which is not currently taking glucocorticoids but has an impaired brain adrenal axis. The second is that which is currently taking glucocorticoids for a chronic disease. The first group is treated as described above. For the second group the surgeon has to account for the tendency of Glucocorticoids (corticosteroids) to cause separation of healed or sutured incisions, increased risk of infection, and delayed healing of open wounds while continuing the glucocorticoid medication they need after surgery. Glucocorticoids produce these effects by interfering with inflammation, fibroblast proliferation, collagen synthesis and degradation, deposition of connective tissue ground substances, angiogenesis, wound contraction, and re-epithelialization. Vitamin A restores the inflammatory response and promotes epithelialization and the synthesis of collagen and ground substances. However, vitamin A does not reverse the detrimental effects of glucocorticoids on wound contraction and infection. The RDA for vitamin A is 3,000 IU per day. To reverse the effect of glucocorticoids on healing 10,000 IU per day for 2 to 3 weeks after surgery should suffice for those that are not vitamin A deficient and is well within the range of what could be toxic. This would have to be given in addition to the hydrocortisone, prednisone, dexamethasone or glucocorticoid that was being taken prior to surgery.

In summary before surgery your surgeon needs to know which specific glucocorticoid medication was prescribed/taken, what the doseage was, how long it was taken for, if it was taken daily or intermittently and when it was stopped. All of these variables can impact the safety of your cosmetic surgery.

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Tuesday, July 10, 2018

Coolsculpt Cryolipolysis (Freezing Fat) Can Make You Fatter

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Studies freezing fat in order to remove it without surgery were first done in 2008. Since then Cryolipolysis coolsculpting has become the most popular noninvasive fat reduction procedure in the world. Cryolipolysis involves the noninvasive cooling of fat to selectively kill fat cells without injuring surrounding non-fat tissue. These cells slowly dissolve and gradually release the fat contained within them. It takes 2-4 months for this process to reduce the fat layer and the results of a cryolipolysis treatment become visible. A just published review of patients undergoing the procedure between 2013 and 2016 revealed that as many as 1 out of every 138 cryolipolysis treatments has the opposite effect. Those patients develop paradoxical adipose hyperplasia (PAH) i.e. the fat in the treated area grows larger becoming noticeable up to 3 months following the treatment. There have been no described cases of this resolving on its own.

The combination of suction and cold in #coolsculpting initiates an inflammatory response in some individuals most likely in response to dying fat cells resulting in enlargement and/or proliferation of the adjacent fat cells. It is currently unclear if this is mostly due to machine settings, genetic predisposition or technical aspects of the treatment. While inflamed the pinched fat feels hard and may be tender to pinch. It takes 6 to 9 months after the initial coolsculpting treatment for the inflammation to resolve and the fat to soften on pinch. The treatment for PAH is standard surgical liposuction but if the surgery is performed before the fat softens/inflammation resolves it will only stimulate the fat to grow even more. Unfortunately more than 1 liposuction treatment may be required, liposuction that employs heat (laser assisted liposuction, Vaser...) compound the problem and
paradoxical adipose hyperplasia after coolsculpting
paradoxical adipose hyperplasia after coolsculpting that has stretched the skin

if this occurs on the abdomen it can stretch the skin turning a patient for whom liposuction would have been sufficient before coolsculpting to someone who requires an abdominoplasty/tummy tuck after coolsculpting.

The incidence of PAH after coosculpting is high enough that it should be on the consent forms for the treatments to meet the definition of informed consent for the treatments.

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Liposuction and its variants tumescent liposuction, superficial liposuction, smartlipo, power assisted liposuction, microliposculpture, smartlipo

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Tuesday, May 22, 2018

Armpit Rolls and Tail of the Breast

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Armpit Rolls
Armpit rolls are folds of skin and fat that lie at the upper front edge of the armpit. They make some women self conscious about wearing spaghetti strap tops or strapless dresses and bras. Their presence can be independent of breast size or patient weight
armpit rolls are independent of breast size
Armpit Rolls Are Independent of Breast Size as Seen Before and After Breast Reduction Surgery



Wednesday, April 4, 2018

Seborrheic Keratosis/Keratoses - Warts

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Seborrheic keratoses are common superficial skin tumors made up of immature superficial skin cells and sometimes referred to as warts. They usually develop after the age of 50, but they can also appear in young adulthood. There is a genetic predisposition to develop a high number of seborrheic keratoses, although the precise inheritance pattern is unknown. Their cause is unknown but UV radiation/sun exposure or human papillomavirus (HPV) infection are suspected. They have well defined borders and are well-demarcated, round or oval skin lesions with a dull, uneven cauliflower like surface and a typical stuck-on appearance. Over time they can grow and become darker in color. Virtually everyone will have these if they live long enough.

They generally do not cause any symptoms, but chronic irritation due to friction trauma may occasionally cause itching, pain, or bleeding. The diagnosis of seborrheic keratosis is usually based on their appearance of being "stuck on," warty, distinctly margined, often scaly dark superficial skin lesions located most commonly on the trunk, face, and upper extremities but they can occur anywhere that you have skin including the scalp. Since they are benign and slow growing health insurance does not cover their removal unless there is a suspicion of skin cancer or the keratosis becomes infected etc. While most are clearly visible as keratoses some keratoses are hard to differentiate from a cancer in which case a biopsy is required to know for sure.

The most common treatment is freezing (cryotherapy) followed by shaving, excision, electrodessication (burning with an electric current) or burning it off with a laser. Other than shaving or excision the other methods of treatment destroy the tissue so a definitive diagnosis under the microscope is not possible. Also each of these methods of removal leave a scar. Cryotherapy also removes skin pigment leaving you with a visible white spot so its use is limited in darker skinned individuals.

A new treatment has recently been FDA approved and is now available in the US.
Eskata is a 40% hydrogen peroxide solution dispensed in a pen brush applicator. 2 applications (4 times each 1 minute apart per visit) 2 to 3 weeks apart completely removes most seborrheic keratoses  and the results I have seen are remarkable. It is like a pencil eraser for keratoses. The most common side effects of ESKATA include itching, stinging, crusting, swelling, redness and scaling. It is only available in doctors' offices for application by doctors wearing gloves because it cannot be applied to mucous membranes, causes significant scarring if applied to normal skin and is extremely dangerous if it gets in/on your eyes.

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Saturday, February 10, 2018

#FatGrafting vs. #ChinImplant

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According to American Society of Plastic Surgeons procedural statistics
between 2000 and 2016 there was a 6% decrease in all cosmetic surgery performed but a 38% decrease in the number of chin operations performed. Between 2013 and 2016 there was a 14% increase in all cosmetic surgery but a 13% decrease in the number of chin augmentation operations. 78% of that decrease were women. Clearly chin surgery is becoming less popular especially for women.



Monday, January 29, 2018

Cosmetic Surgery After Splenectomy

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The spleen  is located in the left upper abdomen under the rib cage.

The spleen's key function is the removal of old red blood cells (RBCs), defective circulating blood cells, and circulating bacteria. In addition, the spleen helps maintain normal red blood cell appearance by processing immature red blood cells, removing their nuclei, and changing the shape of the cellular membrane. Other functions of the spleen include the removal of nuclear remnants of red blood cells, denatured hemoglobin, and iron granules and the manufacture of opsonins (properdin and tuftsin). It is recognized as the host for immune cells essential for antibody production and filters out blood impurities, particularly encapsulated bacteria. It also functions as a secondary source of red blood cells if the bone marrow fails to produce sufficient red blood cells. The spleen can become enlarged  in a variety of conditions such as malaria, mononucleosis and most commonly in cancers of the lymphatics, such as lymphomas or leukemia. A very large spleen is prone to rupture resulting in severe blood loss.



Wednesday, October 18, 2017

Thyroid Disease (Hypo and hyper Thyroidism) and Plastic Surgery

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The function of the thyroid gland in the neck is to take iodine, found in many foods, and convert it into thyroid hormones: thyroxine (T4 with 4 iodine atoms) and triiodothyronine (T3 with 3 iodine atoms) by combining it with the amino acid tyrosine. The normal thyroid gland produces about 80% T4 and about 20% T3 and T4 is mostly converted to T3 in the liver and kidneys. T3 is over 3 times more potent than T4. Thyroid cells are the only cells in the body which can absorb iodine. Iodine deficiency historically common inland and associated with the lack of food originating in the sea causes the thyroid gland to swell forming goiters. Worldwide, over 90% of goiter cases are caused by iodine deficiency.



Monday, September 25, 2017

Microneedling with Dermaroller or DermaPen

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Photodamage and the aging process damage the layers of the skin. Wrinkles appear due to loss of structural matrix components outside skin cells (collagen and elastin), dehydration from loss of hyaluronic acid (HA) in the tissue and overall thinning of superficial epidermal and deep dermal skin layers. Microneedling with a dermaroller involves rolling a cylindrical drum with fine needles over the skin surface.
DERMAROLLER

These rollers are available from online vendors, drug store chains and department stores for home use. The needle size ranges from 0.25mm up to 2mm in diameter and various lengths. Some rollers come with interchangeable heads containing different needle sizes. The needles are embedded in a rotating cylinder that can hold up to 200 needles. By rolling the device over the skin the needles create minuscule holes that close within minutes after the treatment without any visible traces in the epidermis or stratum corneum layers of the skin. A hand held pen with oscillating needles is also available for physician use called DermaPen. Each puncture creates a micro-channel in each punctured layer with a surrounding micro-area of inflammation (accumulation of immune cells such as neutrophils and macrophages) in response to the injury. Creation of the holes allows greater absorption of cosmeceuticals or skin creams applied to the skin surface. A healing cell proliferating process follows with formation of new small blood vessels/capillaries, replenishment of structural matrix components (collagen, proelastin, hyaluronic acid, glycosaminoglycans like glucoseamine) by recruited fibroblast cells and surface skin cells growing of the small holes resulting in a smoother skin surface with tighter pores. 6 to 8 weeks after a single treatment 1.1 to 10 fold increases in skin elastin have been found as well as new collagen formation and increased dermal thickness.



Thursday, August 31, 2017

Vitamin B3 - Niacin Prevents Skin Cancer

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Nearly 5 million people are treated for skin cancer in the U.S. each year, and 1 out of 5 Americans (20% of the population) will develop a skin cancer in their lifetime. The risk of developing a skin cancer increases with immunosupression after transplants, prolonged sun exposure and prior radiation treatment of the skin. The two most common forms are basal cell carcinoma and squamous cell carcinoma. Each year melanoma, the most dangerous type, occurs in about 73,000 people in the U.S. and kills more than 9,900.
Back in 2015 Australian researchers found that of 386 patients with non-melanoma skin cancers randomized to taking oral 500mg Vitamin B3 (Niacin) vs. a placebo twice daily that those taking the vitamin cut their chances of developing a new skin cancer by 23% at 12 months and their chances of developing precancerous actinic keratoses by 20% at 9 months. 6 months after stopping the vitamin both groups were at equivalent risk. At that time it wasn't clear if everyone would benefit from taking Vitamin B3 or just those with a previous history of skin cancer. Since Niacin is associated with flushing, headaches and low blood pressure the Nicotinamide or Niacinamide form is recommend to avoid these side effects.

Niacin cannot be directly converted to nicotinamide, but both compounds are precursors of the coenzymes nicotinamide adenine dinucleotide (NAD) and nicotinamide adenine dinucleotide phosphate (NADP). The coenzymes are required for the metabolic breakdown of fat, carbohydrate, protein and alcohol, the metabolic construction fatty acids and cholesterol and the repair of DNA. The recommended daily allowance for adults is 14 to 20mg per day. The highest concentrations are found in skipjack tuna, sesame seeds, whole grain flour, turkey, pork and venison but most grocery bought foods are fortified with niacin. Severe niacin deficiency causes pellagra, which is characterized by diarrhea, dermatitis of sun exposed areas, and dementia, as well as Casal's necklace lesions on the lower neck, hyperpigmentation, thickening of the skin, inflammation of the mouth and tongue, digestive disturbances, amnesia, delirium, and eventually death, if left untreated. On the other hand overdoses of niacin can cause liver failure, reversible eye damage and abnormal hear rhythm. Niacin can be manufactured by the liver from the essential amino acid tryptophan.

The sun's ultraviolet rays damage skin cell DNA and suppress the skin's local immune system from removing abnormal cells thereby contributing to the onset of skin cancer. Vitamin B3 counteracts both of these ultraviolet ray reactions. In animal models and in vitro, niacin produces marked anti-inflammatory effects in a variety of tissues – including the brain, gastrointestinal tract, skin, and vascular tissue. Since 2015 in vitro studies conducted with melanocytes (skin pigment cells) and melanoma cells have shown that nicotinamide has the same effect on these cells. Randomized placebo-controlled trials are now planned to determine the efficacy and safety of nicotinamide for melanoma prevention in high-risk patients.
Topical nicotinamide at concentrations up to 5% can be applied with a low incidence of skin irritation. When applied to the skin it has been shown to increase skin barrier properties, decrease skin sensitivity to skin irritants, reduce fine lines and wrinkles, improve skin tone and elasticity and reverse sun exposure aging changes of the skin. It has also been used in the treatment of psoriasis. It is unknown if topical nicotinamide protects against skin cancer but there is evidence to support it's addition to sunscreens.

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Skin Cancer

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Monday, August 21, 2017

Global Plastic Surgery 2016

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