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.

Call today for a consultation!
310-246-0537

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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.

Chin enlargement can be achieved by bone surgery (genioplasty), chin implant placement or injection of temporary or permanent fillers. Chin implant placement is currently the most popular method of chin enlargement. The implants can be made of silicone, goretex or medpor. Each method and type of implant is associated with its own pros and cons. The decrease in number of augmentation surgeries being performed is therefore likely due to dissatisfaction with chin implants. I covered the pros and cons of different implant materials in a previously blog Facial Implants - cheeks, chin, jaw.  The assessment of results for any of these methods focuses on the front to back chin projection, resolution of dimpled chin skin (mentalis muscle strain) and symmetry visible on a frontal view. For middle aged and older patients the presence and severity of marionette lines and lower lip-chin grooves also impact the results and are less likely to be improved by implants alone. This blog will focus on the methods themselves and their pros and cons.


Method Pros Cons
bone surgery (genioplasty) can lengthen vertically and front to back more swelling longer recovery time, blood supply to bone can be compromised, step off at outer corners of the bone cut, teeth can be damaged
chin implant permanent, squared male chin achievable visibility, possible implant displacement, possible infection
injectable filler local anesthesia only, quick recovery most only give temporary result, can only increase front to back projection
injected fat graft can be performed under local anesthesia, ideal for lower lip-chin groove filling, permanent unpredictable fat survival that can cause uneven contour or asymmetry, cannot form a square male chin, can only increase front to back projection, may need more than 1 session to achieve the desired result, can change with weight gain or loss

Although fat grafts and injectable fillers can soften marionette lines the ideal way to remove those lines is a facelift.
Squared Male           Round Female Chin

Square Male Medpor Chin Implant

Round Female Silicone Chin Implant

A published prospective study of 42 consecutive patients (32 female and 10 male aged 19 to 50 years mean age 28 years) who underwent chin augmentation by means of fat grafting between October of 2014 and January of 2016 showed that injection of 4 to 10cc (average 7.5cc) of fat reliably augmented the chin. All patients had not previously had chin surgery and wanted/needed only front to back chin augmentation without vertical lengthening. At 6 month follow up after surgery these patients retained 82% of the injected fat with resulting increased front to back chin projections of 3 to 11mm (average 7mm). The degree of fat survival was not related to the amount of fat injection in these small amounts. Only 3 of these patients requested another procedure for additional chin projection despite all 3 having gained more than 6mm in projection from the first procedure.

Weakness of the chin has been associated with up to 30 percent of rhinoplasty patients. Nevertheless, many rhinoplasty patients are not ready to commit to an implant to improve the chin area. These patients are much more likely to accept fat grafting to improve the chin contour. The recent increasing use of injected fat graft chin augmentation may make chin augmentation more popular with female patients.
Chin Implant Patient

Before (top) and 5 months after (bottom) surgery photos of secondary facelift and injection fat grafting to the chin. The marionette and laugh lines were reduced by a combination of facelift and fat grafting. 5cc of fat was placed in the lower lip chin groove and 8cc was placed directly into the chin. To rejuvenate the area and reduce chin dimpling (mentalis muscle strain).

Call today for a consultation!
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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.



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