Showing posts with label cosmetic surgery. Show all posts
Showing posts with label cosmetic surgery. Show all posts

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
     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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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. These patients are deficient in C1-esterase inhibitor protein so the metabolic pathway depicted in the above diagram goes into overdrive. 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.

Sunday, October 20, 2013

Heart - Coronary Artery Stents and Cosmetic Surgery

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Heart (coronary) artery blockage is a local blocking or narrowing in the arteries on the outer surface of the heart by accumulated deposits of plaque, which is mostly bad cholesterol. Every artery in the body is a blood pipeline. These pipelines get blocked with accumulation of bad cholesterol. When a cardiologist suspects blockage or narrowing of any of these heart arteries he/she will perform an angiography (threading a catheter up a thigh artery to the heart to inject a dye that is visible on X-ray) to view the inside of the arteries. When an area of artery narrowing or blockage is identified a catheter with a balloon is inserted along the same path and inflated at the problem area to open it up. This is called angioplasty. Increasingly stents are placed at these angioplasty sites to keep them open in the long term. In some cases multiple stents are sequentially placed in the same artery. If the area cannot be treated in such a fashion open heart surgery is required which involves opening the rib cage and bypassing the blocked area with a vein graft or connecting an artery from inside the rib cage to the downstream side of the blockage. These procedures have helped prolong the life of countless heart disease victims. This blog only addresses patients who have had stents placed. It does not address those who have had open heart surgery.

Tuesday, October 1, 2013

Blood Clots, Venous Thromboembolism, Pulmonary Embolus and Cosmetic Surgery

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In a previous blog I discussed Bleeding Disorders and Cosmetic Surgery focusing on bleeding tendencies and abnormally low blood clotting. This blog deals with the other side of the coin abnormally high blood clotting. These clots usually form in large veins of the leg or pelvis or in the chambers of diseased hearts.

Tuesday, July 17, 2012

Groupon and Discount Coupons for Cosmetic Surgery

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Social media coupon sites such as Groupon and Living Social entice consumers to buy online coupons for products, services and procedures offered by a provider at a reduced price with the addition of a viral component in terms of likes and comments that appear on users facebook timelines.
These social media sites receive payment based on the number of consumer participants, and the arrangement generally brings higher-than-normal customer volume to the providers - in this case, plastic surgeons. However, some elements of this marketing should raise red flags with surgeons as well as patients, including:
  • Exaggerated language in the offering: Numerous sites use extreme exaggerations to garner attention
  • Lack of medical review: The only requirement the customer must meet is to purchase the coupon, which means that services or procedures are offered to potential patients without regard to medical suitability

Sunday, August 7, 2011

Bleeding Disorders, Hemophilia, Antithrombin III Deficiency, Aspirin, Abnormal Platelet Count, Anticoagulation, Blood Clots and Cosmetic Surgery

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Blood clot formation is a complex process involving first the accumulation of cells in the blood called platelets to form a plug and then a number of proteins/enzymes also called clotting factors that act upon one another in a specific sequence one after the other like dominoes dropping called a cascade to form a mesh that reinforces the platelet plug. The end result of which we see and call a clot. The platelets are the white circles in the video below. The cascade allows immense production of clot in a shorter period of time from a small amount of initiating stimulus so it has been programmed into our systems through evolution i.e.the organism that can stop bleeding the quickest after injury has the best chance of surviving. Along the way there are built in inhibitory enzymes at different parts of the cascade so that the cascade does not get out of control and turn your bloodstream into a solid clot.
blood clotting cascade

Tuesday, July 19, 2011

Sickle Cell Disease and Cosmetic Surgery

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Hemoglobin is the protein in red blood cells that carries oxygen. It is encoded by 2 genes in one's DNA, 1 gene from each parent. Either or both of these genes can have a sickle cell trait so that the hemoglobin produced by either or both as the case may be is abnormal. If only one gene is abnormal the individual is said to have sickle trait. If both are involved the individual has sickle cell disease. The sickle gene is most commonly found in those of sub-Saharan African descent. It is thought that that is because the sickle trait confers resistance to the malaria that is present there. 0.5% of the Afro-American population has both genes and 8% have the trait. Under low oxygen levels the sickle hemoglobin changes shape and makes the red blood cell it is in turn into a sickle shape. Conditions that make the abnormal cells sickle include lowered body temperature, infections, acidic metabolic conditions, dehydration and as mentioned lowered blood oxygen levels. The sickle shaped blood cells have a shorter life span and tend to get caught in the smaller blood vessels of the body. The manifestation of this depends on the percentage of total body red blood cells/hemoglobin that is abnormal. Those with only the trait (one gene) have an easier time. When the percentage is high it is associated with anemia, stunted growth, sores on the legs, heart problems, shortened life span, organ failure etc.
sickle cell disease

The effect on cosmetic surgery and the measures needed to ensure safe surgery depend on the percentage. At low percentages you do not need to do anything different from other patients. At higher percentages the patient may need pre-surgery treatment with one or more of the following supplemental oxygen, blood transfusion, over-hydration, folic acid supplementation, vaccinations etc. In some cases the abnormal cells are trapped in the spleen so the peripheral blood tests may only show anemia with immature red blood cells as the bone marrow compensates by ramping up production of red blood cells. The absence of visible peripheral sickle cells in such cases does not mean the patient is a lower risk for surgery. None of these patients should undergo prolonged operations and if necessary surgery should be staged. If the percentage is very high the patient should probably not be having elective cosmetic surgery. If you are prone to sickle cell crises or have sickle cell related skin sores you should not have any cosmetic surgery. Your surgeon needs to work together with a hematologist in order to ensure a smooth recovery after surgery.

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Monday, May 30, 2011

Diabetes and Cosmetic Surgery

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Diabetes in all its forms (diet controlled, medication controlled and insulin controlled) impacts all surgery patients.  Since diabetics are more prone to coronary artery disease and blood chemistry alterations they require more extensive lab work including electrocardiograms before surgery and should be medically cleared for surgery by their internist. After surgery their healing time is prolonged, fluid balance is altered and they are more prone to infection. Therefore care after surgery including insulin doses should be performed under the guidance of the physician who medically cleared the patient for surgery accounting for the type of surgery performed and the patient's condition.

Monday, February 2, 2009

Facial Proportions - Facial Analysis in Cosmetic Surgery

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Faces that are considered youthful and attractive in general have certain proportions and relationships in common. These fall into 3 categories.
  • The first is equivalent size where 2 different anatomical structures have the same size.
  • The second is proportional size where one structure is a specific fraction size of another.
  • The third is positional angle relationships between 2 structures.

The optimal values for the first 2 categories are the same for both sexes. The third category can be altered to achieve a more masculine or feminine look. In assessing a patient for facial surgery Plastic Surgeons must keep these proportions in mind in the process of deciding what specific operative procedures would benefit the patient. This also allows the surgeon to custom tailor the procedure for each patient. No 2 patients should have the exact same procedure unless maybe they are identical twins. This is especially important when the margin of error is small such as a rhinoplasty where the margin of error is a millimeter or less.

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