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.

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 Dr. Aaron Stone - Plastic Surgeon Los Angeles
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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.

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 drainage	20%

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
Aaron Stone MD - Plastic Surgeon Los Angeles
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4 Types of People Who Should Not Have Plastic Surgery

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1. Nothing left to fill or do 
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.
2. Copycats 
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.

3. Doctor shoppers 
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.
4. Fit specific profiles
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
Dr. Aaron Stone - Plastic Surgeon Los Angeles
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Skin Aging and Wrinkling by City and State

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Skincare, maker of topical anti-aging skin care products, partners with , an analyzer of American city demographics, to produce a yearly ranking of US cities with respect to skin aging and wrinkling. In their analyses the top 5 factors contributing to skin aging/wrinkling are low winter temperatures, extreme weather temperatures, commuter times, sunny days (UV exposure), and elevation. Other contributors are stressful living, dry heat, ozone pollution, sleep deprivation and smoking rates. Although UVB is blocked by glass up to 72% of the UVA radiation of the sun, that which damages and ages the skin, still penetrates ordinary glass. So those with long commutes have significant sun exposure. The risks for skin wrinkles obviously overlaps with skin cancer risks. In 2015 New York was the most wrinkle prone and Alaska was the least most wrinkle prone state. California came in at 36th , Texas at 38th and Florida at 32nd.

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.

In 2015 the USA, Brazil, Mexico and South Korea accounted for 9.6% of the world’s population.

Yet the USA accounted for 75% of the world’s total breast implant placement and 56% of its saline breast implant placements.

Non-Surgical Rhinoplasty

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Asian Patient Before-After Surgical Rhinoplasty with Medpor Implant to the Bridge

Non-surgical rhinoplasty has been around since the early 1900’s when surgeons used liquid paraffin to correct nasal imbalances. Although the corrections proved effective, the paraffin wound up being harmful to the body. As were the silicone fillers of the 1960’s. It’s only recently with the advent of hyaluronic acid fillers such as Voluma, Belotero, Juvederm and Restylane that the non-surgical rhinoplasty has become a plausible reality.

This month an article published in Dermatologic Surgery and another in Aesthetic Surgery Journal tout the benefits of non-surgical rhinoplasty with injection of a hyaluronate filler into the nose. The first out of a South Korean clinic used the filler to augment the bridge and/or rotate the tip with a 1% rate of vascular complications. Those cases were attributed to the use of a needle instead of a cannula but they did prove the efficacy of the procedure. The second looked at Asian patients in Australia and Brazil undergoing the procedure and reported that nearly 80% were satisfied or very satisfied with the filler treatment 12 months out. 85 to 90% said they would recommend the procedures to others. It is not clear which hyaluronate is best for this procedure or if other types of fillers can/should be used.

The take home message is non-surgical filler rhinoplasty can produce temporary results that are comparable to surgical augmentation rhinoplasty. However, the key word is temporary and this is likely best used on the bridge below the radix level or injected from below upwards. Injections directly into the radix near the eyebrow level, in the tip or on the sides/creases of the nose where the blood vessels are is more likely to result in vascular complications i.e. skin and possibly deeper tissue loss. The material can cause a problem by being injected directly into an artery or vein or by compressing a blood vessel by mass effect. Some fillers absorb water over time like a sponge so their compressive effect is delayed. There is a remote chance the injected material migrates to the eye causing blindness. Consent forms for the procedure should list the possible complications of blindness and skin loss due to vascular compromise. If you have increasing intolerable pain after these injections you may have impending skin loss and need to be treated within 24 hours. The best way to avoid a complication is to not inject directly into the areas described above, make a skin hole with a small 22G needle near the midline and then inject 0.1cc aliquots through this hole with a 25G blunt tipped cannula just superficial to the periosteum and deep to the blood vessels. Some doctors mix the hyaluronate with local anesthetic to thin it and make it less likely to adversely affect blood vessels.

The best candidates for this procedure are those with deficient nasal bridges and thick nasal skin (like Asians), those who cannot undergo the down time associated with surgery or take time off work, those who are prone to or afraid of complications like scar contracture or thinning of the nasal tip and those who cannot afford surgery or want to try out the surgical result before committing to surgery. If you have had a bad experience with previous rhinoplasty surgery you might be more willing to undergo a non-surgical correction of the problem. You of course cannot refine the nasal tip, make a big nose smaller, fix valve collapse (although some doctors believe it can temporarily resolve internal valve collapse), narrow a boxy tip, decrease tip projection, treat impaired airflow due to septal deviation, change columellar show or narrow the alar base by just injecting filler. Non-surgical temporary filler rhinoplasty has a role when filler is placed directly on top of bone or cartilage to fill a depression, camouflage a hump, change the nose lip angle or raise the tip slightly but it cannot replace rhinoplasty surgery and their use in this setting is off label i.e. not FDA approved at this time. Permanent fillers should not be injected into the nose because of the risk of vascular compromise, uncorrectable irregularities and granulomas.

December 21, 2017 Addendum:
A just published review of publicly available court records involving malpractice litigation arising from soft-tissue fillers used in the face found that dorsal nasal bridge injections were significantly associated with blindness. Therefore you should think twice before undergoing non-surgical rhinoplasty.

Dr. Aaron Stone - Plastic Surgeon Los Angeles
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Opioid Prescriptions and Pain Following Surgery.

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Over the last few years the state and federal governments have been making it harder for doctors to prescribe opioid pain medications outside of the hospital, even after surgery. After my initial panic response I found alternatives in the medical literature. Since then I have been prescribing a Tylenol Motrin mix that has worked well in my mostly healthy patient population after surgery. In fact some patients have told me they prefer this approach to the standard opioid prescriptions because of the nausea, constipation, loss of concentration etc. associated with opioids. Now researchers from Stanford University School of Medicine published a review of the records of more than 641,000 patients who underwent one of 11 common operations and were not taking opioid pain medication during the year prior to surgery. They found that some patients were 1.5 to 5 times more likely at risk for chronic opioid use/abuse following surgery depending on the procedure. Males, the elderly, patients with a history of drug or alcohol abuse and those taking Valium like medications prior to surgery were at higher risk though the overall risk was low at about 1%. Now if the hospitals and surgery centers carried Exparel life would be much easier.

Controlling Pain After Cosmetic Surgery
Dr. Aaron Stone - Plastic Surgeon Los Angeles
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Eyelid Bumps

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Syringomas are benign tumors of eccrine sweat ducts in the skin, first described in 1872. They appear as solitary or multiple small (1 to 3 mm diameter), soft to firm, skin-colored to slightly yellowish symmetrically distributed papules or bumps. The distribution may be localized or generalized. Localized syringomas are the most common and are usually found on the eyelids. Generalized syringomas are found mainly on the chest and neck, followed by the forearms. However, syringomas may appear on other body areas such as the penis, armpits, and buttocks. They are presumed to be due to chronic inflammation of the sweat glands or plugging of their ducts by the overgrowth of skin.

Syringoma localized to the lower eyelid.

Generalized syringoma of the neck and chest.

They usually appear at puberty or in the third and fourth decades of life and are more common in Asians, African Americans and females. Family inherited cases have been described. Since they are not associated with any symptoms or cancers they are mainly a cosmetic problem. A number of treatment modalities are available, including surgical excision by scalpel or punch, Erbium or CO2 laser surgery, electrodesiccation, dermabrasion, chemical peeling, cryotherapy, topical tretinoin (retin-A), and combinations of these methods but complete removal is uncommon and no single treatment method has been shown to consistently work. Since they extend below the skin surface a superficial treatment alone will not suffice and because they tend to be multiple it is safer to treat them in a piecemeal fashion. Punch excision of larger lesions and a trial of low-voltage electrodessication and trichloroacetic acid chemical peel are suggested before treating all lesions. Syringomas are particularly difficult to treat in darker skinned individuals because of the added risk of skin discoloration or bad scarring.

Dr. Aaron Stone - Plastic Surgeon Los Angeles
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Labiaplasty and Vaginoplasty

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Vaginal labiaplasty or simply labiaplasty refers to surgical reduction of the size of the labia minora or creation of labia in transgender surgery. This blog only covers the reduction surgery. The procedure has become an increasingly popular in recent years and is carried out for a variety of reasons. In its 2014 national totals for cosmetic procedures, ASAPS reported surgeons performed 7,535 labiaplasty procedures in 2014. Labiaplasty increased by 49% compared to the prior year, and nearly 90% of those patients were 19 to 50 years old. In 2015 the number of procedures increased another 16% to 8,745. However, the number of labiaplasties performed on girls 18 under was 80% greater in 2015 than 2014, which is alarming. Since these number only include Plastic Surgeons the actual US numbers are likely much higher when procedures performed by Gynecologists are included. During this same period of time breast augmentation for teenagers and adults together only went up 6.7%