#Hidradenitis of the Armpits - Boils Under the Armpits

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Inflammation of the armpit glands or #Hidradenitis, was first described by Velpeau in 1839. In 1854, Verneuitt suggested that this condition might arise from the sweat glands of the skin and described the clinical condition which is now recognized as hidradenitis suppuritiva. Since then, hidradenitis surgeons have recommended many forms of treatment for this entity: lotions, vaccines, fever therapy, toxoids, steroids, ultraviolet light, X-rays, antibiotics, and surgery. The disease does not occur before puberty because the apocrine sweat glands do not function at that age. Patients see this as boils under the armpits that swell, drain foul smelling material and then swell again as the cycle starts over again.

Nasojugal crease, tear trough deformity, nasojugal groove, bags under eyes, under eye hollowness

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In the young individual the transition between lower eyelid and cheek is imperceptible. The dividing line between these areas in older individuals is the nasojugal crease also called the nasojugal groove (term first used in 1961) or tear trough (term first used in 1969). It is an early sign of aging around the eyes, lending a fatigued and aged appearance to the face. As part of the aging process ligaments that fix facial skin to the underlying facial bones thin and lengthen or stretch, facial bones recede back and facial fat shrinks. This results in the drooping of facial skin and appearance of laugh lines, jowls, nasojugal creases, eyelid bags etc.. The skin within the nasojugal groove or crease becomes thinner and/or darker in color than the slightly lower nose or cheek skin. It can also seem deeper or be more visible if there is protrusion of fat into the lower eyelid. The aging process starts near the nose as the tear trough and progresses outwardly towards the same side ear becoming what is called the palpebromalar groove.


Tear Trough and Palpebromalar Groove Boundaries



Examples of Tear Troughs in Younger Patients Without Protruding Eyelid Fat

Gynecomastia

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Gynecomastia means enlargement of the male breast. The definition has nothing to do with what causes the enlargement or what tissue it is composed of. It is most common around puberty & can involve one or both sides of the chest. Most commonly the enlargement is centralized in the breast but occasionally it is not. It is present to some degree in about a third of male population. It appears either early in adolescence or later in the adult years of life and can be very disruptive in the life of a teenager or adult. Working out in the gym, going to the beach and changing in the locker room can become unpleasant ordeals.

Asian Rhinoplasty - AfroAmerican Rhinoplasty

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There are 3 main types of noses - Caucasian, Asian or Oriental and African. The Asian nose has characteristics between those of the Caucasian and African. Today one increasingly finds mixed features between these groups as well so some individuals can have a Caucasian tip with an African bridge or vice versa. The most visible difference is the more vertical nostril alignment with a longer strip of skin between the nostrils in the Caucasian nose vs. the Asian or African nose. The Asian and African nasal bridges are flatter and broader than the Caucasian. In some cases the bridge may be so flat that it appears scooped out or ski sloped. The nasal tip skin is usually thicker with a more rounded tip in the Asian and African noses. The thinner nasal tip skin in the Caucasian nose makes the tip cartilages and their shapes more visible on external viewing.


As you can see in the above diagram these differences are due to differences in the skin but mostly due to differences in the underlying bone and cartilage. In Asian and African noses:

Even a dog can benefit from a facelift

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As you can see even a dog can benefit from a facelift. This Shar pei required a facelift because the extra folds of skin were damaging the dog's eyes.

This Los Angeles billboard was actually an ad for a Comedy Central television show not a Veterinarian or a Plastic Surgeon

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Axillary Hyperhydrosis Hyperhidrosis - Excessive Armpit Sweating

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Excessive seating from the armpits can be very debilitating causing a bad odor, staining of clothing and restriction of social as well as exercise related activities. This problem can also affect the palms of the hands or soles of the feet.

Sweat glands maintain skin surface health and regulate body temperature by supplying water to the skin surfaces for evaporation. Two types of sweat glands are present over human skin, eccrine and apocrine glands. Millions of eccrine glands are distributed throughout the entire body surface and produce a high salt content sweat that is excreted directly onto the skin through an excretory duct. The greatest density of these glands is found in the armpit, palm, and sole of the foot. The apocrine sweat glands are less in number and are distributed over the armpits, around the anus, around the breast nipple complex, and eyebrow regions. In addition to salt, the sweat from these glands contains fat and cholesterol and is excreted indirectly by passing through the shaft of hair follicles. The apocrine gland is 10 times larger than the eccrine gland, and both are present in equal numbers in the armpits. The apocrine glands start secreting at puberty and stop after menopause in women. Overproduction of either gland in the presence of certain skin surface bacteria can produce a bad odor. Clogging of the apocrine glands leads to a condition called hydradenitis suppuritiva with abscesses and draining pus. The treatment for this is surgical removal of the glands together with the damaged skin and then surgical closure of the resulting wound.

Asian Upper Eyelid Surgery - Asian Upper Blepharoplasty

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In the caucasian upper eyelid the deeper layers of the eyelid converge 6 to 8mm above the eyelid margin/eyelashes to create a crease (labeled upper lid crease in the diagram above). In the typical asian upper eyelid these layers do not converge so there is no crease. The absence of this convergence allows fat to descend into the eyelid (as noted in the diagram above) giving the puffy look that is seen in some asian eyelids and the no upper eyelid crease appearance.

Breast Implants Augmentation Reconstruction and a Natural Look

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Most of us know when we see a good result from breast surgery whether it be implants for breast augmentation or reconstruction after breast cancer surgery (mastectomy) or the results of a breast reduction surgery. As I described in my blog on facial proportions analysis a similar proportions assessment is used in planning any breast surgery and in assessing the end result.

That is to say for the average woman between 5 and 6 feet tall the desired proportions are that the nipples form an equilateral triangle with the upper notch of the breast bone and each side of the triangle is about 20cm in length. Additionally the distance between each nipple and the fold under the breast should be about 7cm with a gentle curve outline along the bottom of each breast. Together with equal sized nipple areola complexes this creates the left right symmetry and aesthetic look we strive for. The question then arises as to how one achieves this goal or result after breast surgery. This blog will only deal with breast implants rather than breast reductions and mostly with options available to correct for deviations from this pattern after breast implant placement i.e. redo breast implant surgery when the nipple is in the correct position.

New US Federal Tax on Cosmetic Surgery

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Perhaps you've heard of the current healthcare bill before the US Senate, Page 2045 Sec. 9017, Excise Tax on Elective Cosmetic Medical Procedures included in the Patient Protection and Affordable Care Act. This dense legalese translates to a tax on all cosmetic procedures as partial payment for the healthcare overhaul our current administration is attempting to implement. The provision would add a five percent tax to "cosmetic surgery and medical procedures" to help cover the $849 billion price tag for health care reform. The tax would cover any cosmetic medical procedure deemed "not necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease. The US government is trying to apply a sin tax akin to that on cigarettes and tobacco on cosmetic surgery.

The Internal Bra Breast Lift

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Breast sagging is a common problem women face with aging, breast deflation after breast feeding and/or after the placement of large breast implants. The cause is a disproportion between the size of the breast tissue and the amount of skin enveloping it combined with stretched out and weakened ligaments that connect the breast tissue to the chest wall. This flattens out the top half of the breasts so that most of the remaining breast tissue is in the bottom half of the breasts. Because the problem is related to the skin and breast tissue (fat, breast gland and suspensory ligaments) rather than muscle this problem is unaffected by exercise. Historically the treatment was surgical removal of excess skin sometimes with some manipulation of the breast tissue and/or a breast implant resulting in a firmer breast with more fullness in the upper half of the breast. Removal of skin alone does not always restore the more youthful appearing upper half fullness.

The pattern of skin removal (circle around the nipple, lollipop, inverted-T incision) used depends on the degree of drooping or amount of skin that needs to be removed. For larger skin removals the anchor pattern or inverted-T has been the mainstay. The problem with this is some patients develop large symptomatic scars.