Tuesday, March 21, 2017

Recent Research in Hidradenitis Suppuritiva


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Antibiotic Therapy for HS Can Induce Antibiotic Resistance
A cross-sectional analysis of 239 patients with HS evaluated from 2010 to 2015 compared use of antibiotics to no antibiotics with respect to the development of bacterial resistance to antibiotics.
Tetracyclines and oral clindamycin were not associated with any significant antimicrobial resistance. Therefore they should be used in preference to Bactrim, Ciprofloxacin and topical Clindamycin to treat HS related infections.
Fischer AH, Haskin A, Okoye GA. Patterns of antimicrobial resistance in lesions of hidradenitis suppurativa. JAAD. 2017;76(2)309-213.e2

Skin Microbiota is Altered in Preclinical Hidradenitis Suppurativa
Researchers compared armpit skin not involved with HS in 24 patients with HS to 24 people without HS. 50% of the samples from HS participants showed signs of low-grade inflammation compared with only 16% of controls but there were fewer bacteria and less biofilm on the skin of the HS participants not visibly affected by HS. Therefore the inciting factor of HS is likely autoimmune not bacterial infection from the outside and antibiotic use to prevent HS flare ups is not recommended.
Ring HC, Bay L, Kallenbach K, et al. Normal skin microbiota is altered in pre-clinical hidradenitis suppurativa. Acta Derm Venereol. 2017;97(2):208-213.

Ultrasound Evaluation May Assist in Staging HS Severity
Researchers examined 20 individuals with HS diagnosed lesions between January and September 2016 using high frequency ultrasound systems (UHF48 and UHF70 transducers with M-mode and Color Doppler mode). The ultrasounds showed widening of the hair follicles, thickening and/or abnormal echogenicity of the dermis, dermal pseudocystic nodules, fluid collections, fistulas and dermal sinus tracts connected to the base of hair follicles. They concluded that high frequency ultrasound can help to confirm HS diagnosis, assess the severity of the disease, improve the management of the patients and evaluate the therapeutic effects of systemic and local treatments.
Oranges T, Chiricozzi A, Dini V, et al. High frequency ultrasound in Hidradenitis Suppurativa [presented at the 75th Annual Meeting of the American Academy of Dermatology]. Orlando, Florida. March 3, 2016.

HS Flares Are Often Heralded by Prodromal Symptoms
Researchers administered an extensive questionnaire including questions on the frequency, type and time of occurrence of the prodromal symptoms, and the degree of certainty of the perceived association to 72 patients with HS. 83.3% (60 out of 72) reported experiencing 1 or more prodromal symptoms prior to the development of inflamed nodules or abscesses. 45% indicated that the prodromes occurred more than 24 hours before eruption, while 20% indicated that they occurred 12-24 hours before eruption. In over half of these patients the symptom was fatigue or malaise which is likely related to immune system downgrading or upgrading.
Ring HC, Theut Riis P, Zarchi K, Miller IM, Saunte DM, Jemec GB. Prodromal symptoms in hidradenitis suppurativa [published online February 14, 2017]. Clin Exp Dermatol. doi: 10.1111/ced.13025.

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Laser Hair Removal and Hidradenitis Suppuritiva
Bandages and Dressings for Hidradenitis Suppuritiva
Hidradenitis of the Armpits

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Monday, March 6, 2017

Eyelid Surgery and Headaches


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There are different types of headaches including migraine, tension and cluster headaches. The causes of headache are as variable as the proposed treatments. Over the last 5 to 10 years plastic surgery in the treatment of headaches has become increasingly popular. This blog only deals with eyelid surgery and tension headaches.

Upper eyelid surgery can be cosmetic for the removal of excess skin or reconstructive to improve vision by removal of excess skin and/or eyelid ligament tightening . A cohort study of 108 eyelid skin  removal only cosmetic blepharoplasty and 44 reconstructive skin removal with eyelid drooping blepharoptosis procedures (cosmetic and drooping eyelid surgery) treated between September 1, 2014 and September 1, 2015 were compared using Headache Impact Test-6 scores before and after surgery.  The test scores are derived from questionnaires completed by patients. 35% of the skin only blepharoplasty and 64% of the visually impaired patients had tension headaches before surgery. The scores in the first group went from 56 to 46 and in the second group from 60 to 42 following surgery.
The conclusion is more patients with drooping eyelids affecting vision have headaches than patients who just want cosmetic upper eyelid surgery and though both groups have less severe headaches after surgery those whose vision was affected have more improvement. Additionally the more their vision was affected the greater headache severity they had before surgery and the more relief they had after surgery.

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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.





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.


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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