Bandages and Dressings for #HidradenitisSuppuritiva

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As described in my previous blog post Hidradenitis of the Armpits - Boils Under the Armpits a plug of dead skin in the duct of a gland emptying into a hair follicle in areas of opposing skin surfaces like the armpits, under the breasts and in the groin initiates an infectious process as bacteria multiply within the plugged gland creating a skin boil. The obstructed gland or boil ruptures into the deep layers of the skin; adjacent glands become involved; and abscesses form. Subsequently, multiple draining sinuses or holes appear on the skin surface and the whole hair bearing area may become inflamed. We call this process #HidradenitisSuppuritiva (HS).

As I described my first choice of treatment for this process is surgical removal of the involved skin and closure of the resulting wound with a flap of adjacent normal skin. However, this aggressive surgery is not always the best near term option because of insurance, financial, work or personal reasons. For early stages of the disease temporizing the situation with topical treatments is appropriate and can provide significant relief.

10 Things to Consider Before Having Plastic Surgery

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1. What is my surgeons training background?

Traditionally, doctors from just four medical specialties — plastic surgery, dermatology, otolaryngology (ear, nose and throat), and ophthalmology — have handled the bulk of cosmetic offerings, including everything from minimally invasive aesthetic treatments like botulinum toxin (sold under the brand name Botox) to more involved procedures like face-lifts. And those specialists spend years honing their chops in residency training programs that teach skills unique to each specialty in addition to basic surgical skills. Now doctors in these and other specialties may take a weekend course as the only preparation for doing your surgery. “Unfortunately, this is an industry where the most creative, assertive, sexiest marketing often drives the business, but it may not be someone with the best experience,” said David B. Sarwer, a professor of psychology at the Perelman School of Medicine at the University of Pennsylvania.

Smoking Adversely Affects Facial Aging

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The link between smoking and premature facial aging was first made in 1971. Surveys of twins attending the annual Twin Days Festival, held in Twinsburg, Ohio between 2007 and 2010 conducted by Case Western Reserve University department of Plastic Surgery have corroborated this. In each pair of twins, either one twin smoked and the other did not, or one twin smoked at least five years longer. Pairs in which neither smoked or the difference in smoking was less than 5 years were excluded.Fifty-seven of the included 79 twin pairs studied were women, and the average age was 48. The twins completed questionnaires regarding their medical and lifestyle histories specifically sunscreen use, alcohol intake, work stress and smoking history. A professional photographer took standardized, close-up photographs of each twin's face. Without knowledge of the twins' smoking history, plastic surgeons then analyzed the twins' facial features in the photos, including grading of wrinkles and age-related facial features to identify "specific components of facial aging" that were affected by smoking.

The sister on the left smoked 17 years longer than the one on the right which accounts for larger jowls, lip wrinkles and lower eyelid bags not present in the sister on the right as well as the deeper frown and laugh lines in the sister on the left.

The conclusion of the study was that the effects of smoking on facial aging are most apparent in the lower two-thirds of the face specifically lower eyelid bags, malar bags, upper eyelid skin excess, the lips, laugh lines and jowls.  The forehead wrinkles, frown lines and crow's feet wrinkles were not statistically different.  Smokers had more sagging of the upper eyelids, as well as more bags of the lower eyelids and under the eyes. Twins who smoked also had higher scores for facial wrinkles, including more pronounced nasolabial folds, wrinkling of the upper and lower lips and sagging jowls. I had once had a patient who smoked only holding the cigarette on the right side of her mouth. She had aging wrinkles of the right upper lip but not of the left upper lip. In her case one side of her face aged more than the other.

The take home message is do not smoke to lessen the need for cosmetic surgery and do not smoke afterward to maintain the results of cosmetic surgery for a longer period of time.

Dr. Aaron Stone - Plastic Surgeon Los Angeles
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Heart - Coronary Artery Stents and Cosmetic Surgery

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Heart (coronary) artery blockage is a local blocking or narrowing in the arteries on the outer surface of the heart by accumulated deposits of plaque, which is mostly bad cholesterol. Every artery in the body is a blood pipeline. These pipelines get blocked with accumulation of bad cholesterol. When a cardiologist suspects blockage or narrowing of any of these heart arteries he/she will perform an angiography (threading a catheter up a thigh artery to the heart to inject a dye that is visible on X-ray) to view the inside of the arteries. When an area of artery narrowing or blockage is identified a catheter with a balloon is inserted along the same path and inflated at the problem area to open it up. This is called angioplasty. Increasingly stents are placed at these angioplasty sites to keep them open in the long term. In some cases multiple stents are sequentially placed in the same artery. If the area cannot be treated in such a fashion open heart surgery is required which involves opening the rib cage and bypassing the blocked area with a vein graft or connecting an artery from inside the rib cage to the downstream side of the blockage. These procedures have helped prolong the life of countless heart disease victims. This blog only addresses patients who have had stents placed. It does not address those who have had open heart surgery.

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.