Wednesday, February 15, 2017

Lentigo Maligna and Lentigo Maligna Melanoma


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Lentigo maligna is a melanoma in situ that forms in sun exposed areas of skin, first described in 1892. Under the microscopic one sees a proliferation of atypical pigment cells in the superficial skin. They typically have a cloud like appearance with variable shades of brown coloring and start as a freckle that enlarges over a number of years. Historically they were called Hutchinson's freckle. More than half occur on the face or neck. They are more common in warmer climates with greater sunlight exposure and the majority occur after the 6th decade of life . If ignored long enough they will develop a vertical growth phase and begin to invade the deeper layers of skin, dermis. They are then malignant melanomas and are called lentigo maligna melanoma. At the time of presentation 10 to 20% of lentigo malignas have already invaded the dermis to some degree. Although melanoma represents a small portion of all skin cancers, it is responsible for the majority of skin cancer–related deaths.

The diagnosis of melanoma of the lentigo maligna subtype is challenging, as the clinical presentation is quite varied, ranging from a subtle brown patch to tan/black or even amelanotic(almost normal skin color). These lesions pose significant treatment challenges for clinicians because of significant invisible to the eye surrounding extension, a predilection for cosmetically and functionally sensitive areas, and a naming system that is often confusing. Obtaining a biopsy specimen from a clinically suspicious lesion can present problems, given the lesions can be as large as 6cm in anatomically and cosmetically sensitive areas. If the suspicious lesion is small, an excisional biopsy of the entire pigmented lesion to fat is recommended. However, an excisional biopsy is rarely feasible, as most lesions are too large with poorly defined margins to be completely removed. In this setting, a small biopsy of the darkest, or most palpable, or otherwise most visibly concerning area of the lesion is recommended.


Non-surgical treatment methods including cryotherapy with liquid nitrogen, laser destruction, radiation therapy and topical immunotherapy with imiquimod have recurrence rates as high as 20 to 100%. Surgical removal is the treatment of choice for lentigo maligna/lentigo maligna melanoma but is more challenging than diagnosis because the margin between lentigo maligna and surrounding normal or sun tanned skin can be difficult to determine and the standard pathology method of bread loaf cutting the specimen or frozen section methods under estimate the extent of the condition. Also fat has to be removed with skin to make sure hair follicles that could be involved are included. The 1992 National Institutes of Health consensus statement advised that 5-mm margins at removal (removing the visible lesion with 5mm of surrounding skin) were adequate in the treatment of melanoma in situ, but this recommendation was based on melanomas on the trunk and extremities. In the head and neck region, however, multiple studies have shown that the standard 5-mm margins are inadequate for excising lentigo maligna in up to 50 percent of cases. University of Michigan dermatologists studied 806 patients with 834 head and neck malignant and lentigo melanomas between 1997 and 2006 using a square staged excision approach. They found the mean margin from lesion to clearance for melanoma in situ was 9.3 mm and 13.7 mm for invasive malignant melanoma.


University of Michigan Study Findings


% of cases with clear margins margin 5mm or less margin 10mm or less
lentigo maligna 41% 74.5%
malignant melanoma 3% 52.5%

Therefore the recommended margin for lentigo maligna of the head and neck is now 10mm unless they are on challenging areas like the tip of the nose. This means the holes left after removal can be 2 to 4 times the size of what the patient sees as the skin lesion when looking in the mirror. That can be a large hole! Performing wide excision and immediate complex facial reconstruction for these large defects without knowing the margins are clear can frequently result in incomplete excision, risk for recurrence, and disease progression over time.

The solution to the treatment problem is a 2 staged procedure with clearance of the margins in the first procedure in a thin square, waiting for a pathology report on the specimen and then removal of the skin and fat within that margin at the second procedure. Typically a 2mm double blade is used to remove the thin square allowing en face examination by pathology instead of bread loaf examination. If the margins are not clear the first time additional stages are added removing thin squares at 5mm until the margins are cleared before performing the definitive removal. The University of Michigan dermatologists are recommending use of the staged square excision in all cases of melanoma including malignant melanoma.

Lentigo Maligna of the nose and 5mm margin for excision. 

Lentigo Maligna of the cheek 10mm margin for excision and flap for closure after removal.

Althought this staged excision has the lowest rate of recurrence the rate is still not zero and these patients are also at increased risk of developing other skin cancers. Since more than one-third of the recurrences in the University of Michigan study developed after 5 years these patients need regular follow up with their dermatologist for decades after the initial diagnosis and treatment.

Skin Cancer
Suntanning and Sunscreens

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Thursday, January 26, 2017

Intra-Uterine Device (IUD) Birth Control and Plastic Surgery


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An intrauterine device is a small contraceptive device, often 'T'-shaped, often containing either copper or levonorgestrel, which is inserted into the uterus. They have a 0.2% to 0.8% typical use failure rate, compared to an 18% failure rate for condoms and 9% failure rate for the pill. Hormonal IUDs can last around three to six years depending on the brand, and the non-hormonal IUD can last up to 12 years.
On its website, CNN (1/25/2017, Cohen) reports that since President Trump won the election, more and more women have been getting IUDs, or intrauterine devices, as they fear that getting IUDs will no longer be free after the ACA (Obamacare) is repealed. According to Cecile Richards, president of Planned Parenthood, since early November 2016, the number of women trying to get into to get an IUD has increased 900 percent. Similarly, CNBC (1/25/2017, Mangan) reports on its website that from October to December 2016, doctor office visits that were coded for either insertions or management of intrauterine devices rose by about 19 percent. This was the first time in years that IUD procedures and follow-up visits increased in both November and December of a given year. The implications on women undergoing Plastic Surgery especially with the increasing popularity of fat grafting and dermal fillers is important.

Actinomyces odontolyticus, gram positive bacteria that grow best under low or no oxygen conditions, have been isolated in female genital tract specimens from 4.8% of women fitted with intrauterine contraceptive devices, in 4% of women with pelvic inflammatory disease, and in 1.8% of women without pelvic inflammatory disease. Because of their poor growth in the presence of oxygen it can be hard to culture or grow them from wounds i.e. you can be infected by them with cultures that show no bacterial growth. Culture requires immediate specimen transport and prolonged anaerobic incubation. They are soil and water saprophytes that live off decaying organic matter and grow in unbranched or branched filaments of cells the way mold grows.
Actinomyces
They form hard lumps in infected tissue that soften as they extend through the soft tissue forming multiple draining abscesses containing yellow colored granules composed of actinomyces microcolonies, cellular debris and associated microorganisms. These small granules may be seen as small masses on CT or MRI scans. In advanced cases they can destroy bone.
Actinomyces Infection
Actinomycosis infections are endogenous infections from mucous membranes i.e. you infect yourself. Since they live off decaying matter the combination of blood and injected fat is a perfect environment for them as some of the injected or grafted fat as in a Brazilian buttock lift is dying while awaiting for the ingrowth of blood vessels. When specimens are tested for their presence they are placed on blood agar gels because actinomyces thrive on blood. I am aware of one case where the actinomyces from an old IUD infected the buttocks after fat grafting - Brazilian buttock lift. After more than 6 months of treatment with multiple hospitalizations and operations that patient was left with deformed buttocks. Because the bacteria live off of dead tissue in areas of low oxygen and blood flow they can require 12 to 18 months of antibiotic treatment to clear.

 The published recommendations for actinomycosis prophylaxis are oral hygiene and regular intrauterine device replacement. A review of patients with actinomycosis infections associated with IUDs revealed the average number of years that the IUDs were in place was 5 years. Therefore if you have an IUD and develop an infection after any surgery it is imperative that the IUD be removed until the infection is cleared. If you have an IUD that is 5 or more years old have it removed before you undergo any elective non-superficial surgery. This problem is just rare enough for there to be a delay in diagnosis which will result in deformities. Diagnosis is often delayed and the yellow 'sulfur granules' are helpful but nonspecific for this infection.

Most US health insurance policies have clauses that preclude coverage of cosmetic surgery complications or coverage of complications due to any non-covered procedure or surgery. Since the Affordable Care Act mandates coverage of Implanted contraceptive devices, like intrauterine devices (IUDs) all treatment related to IUD complications are usually currently covered except for employees of a "religious employer" who is exempt from mandated coverage of birth control. This will all change in the coming years with respect to IUDs but the exclusion of coverage for cosmetic surgery complications will remain.

To be forewarned is to be forearmed.

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Thursday, January 19, 2017

Breast Implants and Breastfeeding


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Breastfeeding is a vital function for infant mother bonding, transmission of antibodies to the baby to fight infection etc. All women with breast implants and no other prior breast surgery giving birth at an Argentinian hospital between April 2013 and July 2014 were followed and compared to body matched mothers and babies. After giving birth those with breast implants had insignificantly lower success at breastfeeding at 30 days after giving birth than those women who did not have breast implants: 93% with implants vs. 97% without implants. Also, it did not matter whether the implants were placed via incisions in the crease under the breast or in the outer edge of the areola (skin around the nipple). Therefore we can conclude that most women can establish breastfeeding even if they have breast implants irrespective of how the implants were placed.

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Monday, January 9, 2017

Tattoo Removal


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PicoWay tattoo removal laser (Syneron Candela) surveyed 250 people who had one or more tattoos removed and 100 people who were thinking about removing one or more of their tattoos between 9/29/2016 and 10/6/2016. 83% who had a tattoo removed were planning on getting a new tattoo and were more likely to do so because they know they have the option of removing it. 13% of this group had it removed because they had become parents. The most commonly removed tattoos were a person’s name. Symbols and animals came in a close second and third.

The person who removed the tattos was:

 Of the 100 contemplating removal:

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Monday, January 2, 2017

Angioedema and Cosmetic Surgery


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Angioedema is rapid swelling (edema) of the dermis (deep skin), subcutaneous tissue (fat), mucosa and submucosal tissues (gastrointestinal or other hollow organ lining) that was first described in 1882. It is characterized by repetitive episodes of asymmetric swelling, frequently of the face, lips, tongue, limbs/hands or feet, and genitals that lasts 24 to 60 hours without itching or hives. In the gastrointestinal lining it can cause severe pain and increased girth with or without diarrhea or vomiting leading to unnecessary abdominal or gynecologic surgery. In the respiratory tract including the mouth and throat it can interfere with speech or swallowing and cause life threatening asphyxiation. In the urinary tract it can prevent urination. In the hands or feet it can preclude the use of the hands or ability to walk. In the face the eyes can be swollen shut.

Its prevalence is 1 in 10,000 to 1 in 50,000 individuals. It is classified as:
Acquired (swelling occurs over a few minutes) Hereditary(HAE)-genetic mutation and usually manifests in the second decade of life (swelling occurs over 2 to 8 hours)
immunologic-IgE antibody mediated allergies to foods, drugs or particles in the air like pollen, autoimmune and caused by the body's release of histamine or antibodies against the C1-esterase inhibitor protein type I-decreased levels of C1-esterase inhibitor protein in the blood, 85% of hereditary type
nonimmunologic- side effect to certain medications, particularly Angiotensin Converting Enzyme inhibitors, NSAIDs like motrin, advil or aspirin, birth control pills containing estrogen, food additives that cause increased bradykinin levels type II-dysfunctional C1-esterase inhibitor protein in the blood, 15% of hereditary type
idiopathic-unknown cause type III-abnormal factor XII in blood clotting cascade so it is more active
cancer such as carcinoid or blood cancers

HAE attacks are caused by the production of large amounts of bradykinin, that is normally broken down by C1-esterase inhibitor protein, in the bloodstream.

In the absence of C1-esterase inhibitor protein activity (the yellow dots) bradykinin production continues uncontrolled. FXII is factor XII a component of the blood clotting cascade. Bradykinin increases blood vessel diameter and pore size with leaking resulting in swelling of the tissue through which the blood vessels travel. It is so powerful that 1 microgram injected into the brachial artery increases arm blood flow 6 fold. Dental treatment, particularly tooth extraction, is a recognized trigger of HAE though symptoms may not manifest for many hours or even days after the procedure. A typical course resolves in 5 to 7 days, but in some patients, the clinical manifestations exist up to 6 weeks. Other known triggers are physical/psychological stress, fatigue, menstrual periods, pregnancy, trauma and having a breathing tube placed for anesthesia. 75% of patients with HAE have a relative who suffers from repetitive bouts of swelling. The remaining 25% are spontaneous without an affected relative. The diagnosis can be made by blood tests measuring the blood complement cascade proteins C1 and C4. Unlike allergic edema, HAE attacks do not respond to antihistamines, steroids or adrenaline including Epipens. The attacks vary in frequency, type and severity which contributes to delays in seeking treatment. 50% of HAE patients will have a laryngeal (voice box) attack within their lifetime, 40% of which are fatal if not treated emergently.



Monday, December 19, 2016

Non-Surgical Treatments Cannot Replace Facelift Surgery


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157 patients under the age of 50 who underwent their first face lift at the New York Center for Facial Plastic and Laser Surgery between January 1, 2003, and December 31, 2013 showed that prior to that facelift each patient spent on average a total of $7,000 on nonsurgical treatments. These included fillers, laser, radiofrequency and botox treatments. The patients reported that they appeared 4 years younger after their nonsurgical treatments, but appeared 8 years younger after their facelift. The take home lesson is that nonsurgical treatments are not a replacement for facelift surgery and that is even more true of patients in their 60s and 70s.


Despite that and correcting for the 2008-2009 recession between 2007 and 2015 the population increased by 6.3% while the number of facelifts per year increased by only 6.1%. The percentage of the population undergoing facelift surgery appears to be a relative constant.

How Long Does A Facelift Last?
Face and Neck Lift 1
Face and Neck Lift 2
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Sunday, December 11, 2016

Pilonidal Cyst - Pilonidal Sinus


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Pilonidal cysts or abscess are located over the tailbone where the buttocks meet on the lower back. The cause is believed to be ingrown hair(s) and/or a congenital pilonidal dimple. Pilonidal is Latin for nest of hair. Excessive sitting or pressure on the area is thought to be a predisposing factor. They cause pain and tenderness over the area with itching and opaque yellow (purulent) or bloody drainage. It was first described by the Mayo brothers in 1833. The disease affects 70,000 people in the United States each year, most of them young men between 15 and 35 years of age. It is 7 times more common in dark skinned individuals, though every patient I have ever treated for pilonidal disease was white. It has historically been associated with the military and even earned the nickname "Jeep-rider's disease" in World War II as it was thought to be due to prolonged jeep rides in bumpy vehicles irritating the tailbone area.

video


A 2013 study of 151 military personnel afflicted with pilonidal disease revealed that the recurrence rate of the disease is related to the type of surgery used to treat it.


# Type of Surgery Complication Rate
45 excision and suture closure 62%
22 excision and suturing wound edges down  27%
69 excision and left open to heal 24.6%
15 incision and drainage20%

A 2008 study of over 1000 Israeli soldiers had a recurrence rate of only 16% using the trephine technique and 9 year follow up. Almost 90% were healed at 4 weeks after surgery vs. the months required for healing if left open to heal or the edges are sutured down. Other advantages of the trephine technique are less pain after surgery and a quicker return to work. The best options are therefore excision and flap closure or the trephine technique.

Negative Pressure Wound Therapy

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Thursday, November 24, 2016

4 Types of People Who Should Not Have Plastic Surgery


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  1. Nothing left to fill or do 
  2. Those who have already had so much done that it is impossible to inject more filler or place  even larger breast implants in the current skin envelope. Those who have had so much botox that nothing moves yet they ask for more botox.
  3. Copycats 
  4. Those who want to look like someone, usually a celebrity or model, with completely different features, proportions and/or ethnicity. The goal of Plastic Surgery should be to turn back father time but not mess with mother nature.
  5. Doctor shoppers 
  6. Those who hop from one doctor to the next in order to get various treatments and procedures that may not normally be allowed by one doctor. They have typically seen too many doctors and are unsatisfied with what they were told or what has been done. The have unrealistic expectations and behave like patients visiting pain pill mills.
  7. Fit specific profiles
  8. These include the Body Dysmorphic Disorder (BDD) types who exaggerate perceived flaws and become dysfunctional because of these perceived flaws, the Single, Immature, Male, Overconfident and Narcissistic (SIMON) who are never satisfied with their rhinoplasties and those who have undergone numerous other procedures before but are continually unhappy despite having had acceptable outcomes.
Body Dysmorphic Disorder (BDD) and Plastic Surgery

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Tuesday, August 30, 2016

Skin Aging and Wrinkling by City and State


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Skincare, maker of topical anti-aging skin care products, partners with , an analyzer of American city demographics, to produce a yearly ranking of US cities with respect to skin aging and wrinkling. In their analyses the top 5 factors contributing to skin aging/wrinkling are low winter temperatures, extreme weather temperatures, commuter times, sunny days (UV exposure), and elevation. Other contributors are stressful living, dry heat, ozone pollution, sleep deprivation and smoking rates. Although UVB is blocked by glass up to 72% of the UVA radiation of the sun, that which damages and ages the skin, still penetrates ordinary glass. So those with long commutes have significant sun exposure. The risks for skin wrinkles obviously overlaps with skin cancer risks. In 2015 New York was the most wrinkle prone and Alaska was the least most wrinkle prone state. California came in at 36th , Texas at 38th and Florida at 32nd.




Thursday, August 25, 2016

Plastic Surgery Around the World in 2015


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The International Society of Aesthetic Plastic Surgeons released its worldwide statistics for 2015 which are interesting for the following reasons.
world population 2015
In 2015 the USA, Brazil, Mexico and South Korea accounted for 9.6% of the world’s population.
total world breast implants saline 2015

total world breast implants silicone 2015
Yet the USA accounted for 75% of the world’s total breast implant placement and 56% of its saline breast implant placements.


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