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



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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