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.

Fat Injections to Reconstruct Breasts or Increase Breast Size

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As described in my previous blog Free Fat Grafting grafts of small pieces of fat removed from one area of the body and placed in another area was first attempted in the late 1800s and early 1900s. In 1893, German physician Franz Neuber grafted a piece of upper arm fat to a patient’s cheek. Two years later, in 1895, another German physician, Dr. Karl Czerny, performed the first documented breast augmentation when he grafted a fatty tumor from a patient’s lower back to repair a breast defect. With the introduction of liposuction in the 1980s the available donor source for fat injections rapidly increased. Although a minority of plastic surgeons currently inject fat into the breast to enlarge them for cosmetic reasons the tide is changing. In 1987 the American Society of Plastic Surgeons advised against fat injections into the breast due to concerns that it affected breast cancer detection and the survival rate of injected fat was unreliable. That opinion was reversed in 2008 in the face of increasing evidence that cancer detection and cancer rates themselves were not affected by the procedure. Now the flood gates have opened and everyone even non-plastic surgeons want to inject fat into the breasts.

Varicose Veins

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Varicose veins are visible dilated tortuous veins. The term is usually only applied to those present superficially on the legs but they can occur anywhere including the testicles (varicoceles) and the face. The legs have a deep and superficial system of veins connected by another set of intermediary or perforating veins. The deep and superficial systems run longitudinally and the perforating system runs transversely to connect them. Veins have a lower pressure of blood flow than arteries so forward movement of blood requires massage by the movement of adjacent muscles and valves inside the veins to prevent back flow. The superficial veins become varicose when the perforating or deep veins are damaged allowing back flow or clot closed and/or the valves no longer function normally.
Chronic or large varicose veins can cause discoloration and thickening of the skin, swelling of the ankles and feet, actual skin breakdown with the formation of ulcers, blow out of the dilated veins with sudden high pressure bleeding, pain and aching muscles especially with prolonged standing and easily damaged skin. My father spent long periods of time standing without movement at his job and developed large varicose veins in his lower legs that ached and precluded him from working that way when he was older. This type of stationary standing work or prolonged sitting work (airplane pilots) are risk factors for developing varicose veins.

Lip Lift - Corners of Mouth Lift Surgery for Drooping Corners of Mouth

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The relative positions and shape of the lips and corners of the mouth signify ones age or youthfulness and emotional status (happy, sad, angry). As one ages the upper lip thins, sags and wrinkles. Skin folds or marionette lines appear extending downward from the corners of the mouth and those corners slant downward. The earliest approaches to this area were the surgical facelift and lip lift surgery that removed or repositioned tissue around the mouth specifically removing skin in the area where the lip joins the lip skin (vermilion advancement) or removing skin just beneath the bottom of the nose. The results of doing so however were variable and the scars can be disfiguring. Later came chemical peels and lasers to remove aging wrinkles of the lips. In the 1980s doctors began injecting botox into the muscle that pulls the corner of the mouth downward (the yellow circle in the video below). This gave subtle but temporary results as did injectable fillers in the corners of the mouth. All of the direct surgery to the corners of the mouth that I have seen in the US have had disastrous results with bad scars and/or bizarre appearances with movement.

 Now, from the country that has the most per capita plastic surgery, South Korea, comes the corners of mouth lift. They call it "Smile Lipt" surgery.
In the video it is apparent that when the surgery gives a subtle result it does look good but when done more aggressively makes the patient look like the Joker character from Batman or the main character from Vendetta. Overall the results are better than have been the norm in the US because they appear to focus on the muscles in the corner of the mouth instead of the skin and fat tissue at the corner of the mouth. These skin and fat removal procedures include the “Valentine anguloplasty” after the heart shape of the removed skin at the lip’s edge. That is not to say that muscle surgery alone is better because removal of muscle in this area can create indents.


Patterns of skin removal for lifting drooping corners of the mouth in the West including the valentine anguloplasty and the lentiform excisions. The far right excision pattern includes removal of the marionette line itself and should be reserved for very light skinned patients that have deep marionette lines.

This newly popular surgery has been receiving increasing news coverage.


Face and Neck Lift 1
Face and Neck Lift 2
Aaron Stone MD - Plastic Surgeon Los Angeles
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Xanthelasma, Xanthomas, Eyelid Cholesterol Deposits

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Xanthomas are deposits of fat filled foam or xanthoma cells in the superficial dermal layer of the skin often surrounded by scarring and inflammation. The condition of having them is called xanthelasma. About half of the patients with xanthelasma have a metabolic disorder with increased fat in the blood (Hyperlipoproteinemia type IIa - high blood cholesterol and LDL levels). The fat is transported in a protein capsule so the complex is called a lipoprotein. The treatment for this type of hyperlipoproteinemia is bile acid sequestrants, statins and niacin.

The treatment of xanthomas has been surgical removal of the material with or without overlying skin, laser treatments and chemical peels. The treatment decision tree depends on the size and number of xanthomas and whether they are hard or soft. Hard ones can be uncapped to remove the xanthoma and then the cap of skin is sutured back down. Smaller xanthomas closer to the lower eyelid lashes or upper eyelid creases can be removed with the skin at blepharoplasty. Larger xanthomas needed to be removed in a staged piecemeal fashion. With a 2 or more month interval between surgical excisions.

All xanthelasma patients should have their blood cholesterol and LDL levels checked and treated as needed to prevent recurrence of the xanthomas.

Aaron Stone MD - Plastic Surgeon Los Angeles
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Change the Lines on Your Palms and Change Your Future

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What came first the chicken or the egg and does life's trials and tribulations make the lines or your palms or do the lines predestine your fate? Now in Japan you can change your future by lengthening the life line on your palm or adding money-luck or marriage lines to your palm. Men usually wish to change their business related success lines, such as the fate line（運命線), the money-luck line (金運線) to make profits, and the financial line (財務線) to save what money you make. These three lines, when they come together just right, create what is called the emperor’s line. Women usually request marriage or romance lines on their palms.

An example of the emperor's line.
The procedure takes about 15 minutes and costs about $1000. The surgery is performed with an electric scalpel because lasers and scalpels make inferior lines. Between January 2011 and May 2013, 37 palm plastic surgeries were performed at the Shonan Beauty Clinic in Tokyo, Japan. The clinic briefly advertised the service, but couldn’t keep up with the demand so now it relies solely on word of mouth. Do palm readers ignore man made fate lines?

Aaron Stone MD - Plastic Surgeon Los Angeles
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Teenage Rhinoplasty - Teen Rhinoplasty

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Cosmetic surgery on teens or children is becoming more popular (in 2009 203,000 teens and in 2012 236,000 teens between the ages of 13 and 19 altered their physical appearance) but can be controversial. While adults have appearance altering surgery to stand out or look younger, teens do so to fit in and be more like their average peer.  Not all teens with psychosocial anxiety about a body part have psychological issues, and they should not be dismissed by adults as being too immature to understand their own emotions or automatically be assumed to have primarily psychological problems.

In Australia such surgery is legally restricted. In 2009, breast and nose surgery, liposuction, and Botox on children were banned in Queensland, Australia. Doctors who perform such procedures without medical reason can face up to 2 years in prison. In New South Wales, Australia patients under 18 years of age who are considering cosmetic surgery have undergo a 3-month cooling-off period, followed by consultation with an internist and clinical psychologist before they can have surgery. There are no such regulations in the United States.

Rhinoplasty, nose reshaping surgery, is the most common cosmetic surgery performed on American teens. It is usually performed as same day surgery under general anesthesia. According to the 2010 American Society of Plastic Surgeons report, rhinoplasty made up 45% of all teen plastic surgery procedures. This has been consistent with 44% of teen cosmetic surgeries being rhinoplasty in 2012. Over 30,000 teens a year get nose jobs in the US. The reasons for having the surgery and the specifics of surgery can be much the same as they are for adults:

• Removing a hump on the nose
• Straightening the bridge
• Reshaping the nose's tip
• Increasing or decreasing the size of the nostrils
• Correcting the nose after an injury
• Opening breathing passages
• Making the nose bigger or smaller

But there are additional issues the surgeon has to take into account including:

• is the teenager mature enough and physically old enough to undergo surgery, follow instructions after surgery and wait for complete recovery before judging the result
• are the teenagers motivations for surgery appropriate and are their expectations reasonable
• are the parents supportive and on board

Daily Sunscreen Use Slows The Aging Process

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It has been common knowledge for a number of years that regular sunscreen application prevents skin cancer and the FDA changed the allowed labeling on the counters so they can state this. A study published earlier this month in Annals of Internal Medicine now shows it also slows the aging process.

Researchers at the Queensland Institute of Medical in Australia looked at a group of 900 young and middle-aged, mostly fair skinned men and women under age 55 (to factor out the contribution of genetic aging) that were randomly divided into 2 groups. The first group applied SPF15+ sunscreen to their faces, necks, hands and arms daily. The second group used sunscreen either rarely, or not at all, discretionary sunscreen group. Silicone impressions were taken from the backs of all participants’ hands, at the beginning and then again at the end of the study, 4 1/2 years after it began. Roughly half of the participants worked primarily outdoors, while about four in 10 were regular smokers. The daily sunscreen group showed no detectable increase in skin aging during the course of the study, according to microtopography measures. The visual appearance of aging skin wrinkles from beginning to the end of the study was 24% less in the daily sunscreen group than in the discretionary sunscreen group.

Each group was divided in half again to receive a 30mg beta-carotene supplement or a placebo on a daily basis. The supplement did not affect skin aging in this study. The take home message is that daily sunscreen application can prevent skin cancer, keep you younger looking longer and you are never too young to start applying it. Furthermore, daily sunscreen application does more for you than taking some daily supplements that are believed to be good for your skin.

Suntanning, Tanning, Sunscreens
The Dangers of Sun Exposure
Dr. Aaron Stone - Plastic Surgeon Los Angeles
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Brachioplasty - Upper Arm Lift

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Upper arm fat and skin removal to reduce hanging upper arm skin in obese women was first described in 1930. Cosmetic brachioplasty or upper arm lifts were first described by Argentinian surgeons in 1954 and subsequently became a well established procedure. However, due to the scarring, fluid collections under the skin, nerve damage and wound problems associated with the surgery it was not very popular. According to the American Society of Plastic Surgeons statistics as recently as the year 2000 more than 300 women got upper arm lift procedures in the US. Last year, 2012, the number increased to more than 15,000. 98% of these patients were women, 42% had undergone previous weight loss surgery, 63% were aged 40 to 54 and 33% were over age 55. The total spent on brachioplasties in 2012 was $61 million. What accounts for this 5 fold increase in the number of procedures over 12 years? Some of this is due to the increase in weight loss surgery. Over 200,000 Americans a year undergo some kind of weight-loss surgery, such as gastric bypass.

Malar Bags

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There are 3 separate entities lower eyelid bags, festoons and malar bags.

Lower eyelid bags refers to protruding fat or redundant muscle in the lower eyelid itself above the level of the bone rim under the eye.
Lower Eyelid Bags
Festoons refers to redundant folds of skin with or without muscle in the lower eyelid.

Festoons