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

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).

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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.



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.



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.


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.



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.


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



Thursday, May 31, 2012

Controlling Pain After Cosmetic Surgery

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Pain control during surgery has been quite good for a number of decades. Refinements in recovery from anesthesia to lower the incidence of nausea, shaking etc. after surgery have been accomplished by adjusting the mix of anesthetics used and employing newer medications like propofol, toradol, zofran etc. More recently the focus has been on controlling pain after surgery to lessen the need for narcotics, shorten recovery times after surgery and improve surgical results in general. The opioid narcotic medications commonly used can become addictive, have small windows between effective and overdosing quantities that affect breathing and tend to be constipating.


Monday, March 30, 2009

Lip Augmentation - How to make the lips fuller or bigger

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Lips express emotion, sensuality, and vitality.  As far back as 69 to 30BC Cleopatra used crushed beetles and ants along with red clay, henna, iodine and seaweed to create a red ink-like substance to apply to her lips. Nowadays we have lipstick to make the lips look more prominent.
youthful lips
In the commonly accepted youthful attractive female lips there is a distinct bow shape to the outline of the upper lip, prominent columns of skin are present between the nose and edge of the upper lip with a curving slope lip skin surface, in repose the lower few millimeters of the upper incisors are visible, the upper lip has a greater fullness centrally near the midline of the body and near the outer corners which turn up slightly while the lower lip has more fullness just to either side of the midline.



Monday, March 2, 2009

Negative Pressure Wound Therapy

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Since the beginning of Plastic Surgery as a modern specialty, around World War I, Plastic Surgeons have been consulted to close wounds. In these cases the wound edges could not just be pulled together and sutured because of tissue deficiencies. At that time Plastic Surgeons would raise tubes of tissue (fat and skin) and slowly after multiple operations advance those tubes into the wounds in order to achieve closure.



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.




Friday, January 2, 2009

The Implications of Herbal Medications on Plastic Surgery

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A majority of otherwise healthy individuals currently are regularly taking herbal medications. This may be with multivitamins and or the usual heart or blood pressure etc medications. I myself regularly take glucoseamine and multivitamins. Although many associate these herbs with being more natural with less side effects than pharmaceutically manufactured prescription medications that is not actually true. Especially in the high doses frequently taken these herbs can thin the blood preventing clotting, prevent healing after surgery, have dangerous interactions with medications given at surgery etc. I have personally had to cancel surgery in the middle of an operation because of bleeding that could not be stopped because the patient took goldenseal or high doses of vitamin E within a few days of surgery without telling me. Vitamin E especially in high doses dramatically thins the blood.

Here is a list of commonly used herbal medications and their associated problems:



Friday, October 17, 2008

SKIN INFECTIONS

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Over the last 10 to 20 years there have been increasing changes in the bacteria normally present on the skin surface. They are becoming resistant to antibiotics (methicillin resistant Staph Aureus - MRSA) & this resistance as well as the problems they cause are different than what is seen with bacteria that become resistant from exposure to medications in hospitals. You can think of this as an infection from yourself vs. an infection that comes from someone else or some surface contact (door knobs, tables etc). The flesh eating bacteria that has been mentioned in the media is due to bacteria that produce a chemical that kills tissue at deeper as well as superficial levels. These bacteria may or may not be antibiotic resistant. If caught early enough all are easily treated.



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