Vitamin B3 - Niacin Prevents Skin Cancer

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Nearly 5 million people are treated for skin cancer in the U.S. each year, and 1 out of 5 Americans (20% of the population) will develop a skin cancer in their lifetime. The risk of developing a skin cancer increases with immunosupression after transplants, prolonged sun exposure and prior radiation treatment of the skin. The two most common forms are basal cell carcinoma and squamous cell carcinoma. Each year melanoma, the most dangerous type, occurs in about 73,000 people in the U.S. and kills more than 9,900.

Back in 2015 Australian researchers found that of 386 patients with non-melanoma skin cancers randomized to taking oral 500mg Vitamin B3 (Niacin) vs. a placebo twice daily that those taking the vitamin cut their chances of developing a new skin cancer by 23% at 12 months and their chances of developing precancerous actinic keratoses by 20% at 9 months. 6 months after stopping the vitamin both groups were at equivalent risk. At that time it wasn't clear if everyone would benefit from taking Vitamin B3 or just those with a previous history of skin cancer. Since Niacin is associated with flushing, headaches and low blood pressure the Nicotinamide or Niacinamide form is recommend to avoid these side effects.

Niacin cannot be directly converted to nicotinamide, but both compounds are precursors of the coenzymes nicotinamide adenine dinucleotide (NAD) and nicotinamide adenine dinucleotide phosphate (NADP). The coenzymes are required for the metabolic breakdown of fat, carbohydrate, protein and alcohol, the metabolic construction fatty acids and cholesterol and the repair of DNA. The recommended daily allowance for adults is 14 to 20mg per day. The highest concentrations are found in skipjack tuna, sesame seeds, whole grain flour, turkey, pork and venison but most grocery bought foods are fortified with niacin. Severe niacin deficiency causes pellagra, which is characterized by diarrhea, dermatitis of sun exposed areas, and dementia, as well as Casal's necklace lesions on the lower neck, hyperpigmentation, thickening of the skin, inflammation of the mouth and tongue, digestive disturbances, amnesia, delirium, and eventually death, if left untreated. On the other hand overdoses of niacin can cause liver failure, reversible eye damage and abnormal hear rhythm. Niacin can be manufactured by the liver from the essential amino acid tryptophan.

The sun's ultraviolet rays damage skin cell DNA and suppress the skin's local immune system from removing abnormal cells thereby contributing to the onset of skin cancer. Vitamin B3 counteracts both of these ultraviolet ray reactions. In animal models and in vitro, niacin produces marked anti-inflammatory effects in a variety of tissues – including the brain, gastrointestinal tract, skin, and vascular tissue. Since 2015 in vitro studies conducted with melanocytes (skin pigment cells) and melanoma cells have shown that nicotinamide has the same effect on these cells. Randomized placebo-controlled trials are now planned to determine the efficacy and safety of nicotinamide for melanoma prevention in high-risk patients.

Topical nicotinamide at concentrations up to 5% can be applied with a low incidence of skin irritation. When applied to the skin it has been shown to increase skin barrier properties, decrease skin sensitivity to skin irritants, reduce fine lines and wrinkles, improve skin tone and elasticity and reverse sun exposure aging changes of the skin. It has also been used in the treatment of psoriasis. It is unknown if topical nicotinamide protects against skin cancer but there is evidence to support it's addition to sunscreens.

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Skin Cancer
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Global Plastic Surgery 2016

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Venous Leg Ulcers

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Venous Insufficiency or back up pressure in the leg veins is a vexing problem. Patients are disturbed because of occasional discomfort as well as the cosmetic appearance of the condition, which starts as skin discoloration and almost inevitably progresses to open wounds.

So what can be done for a patient who has failed elevation, compression, pentoxifylline, and aspirin?

The Research
An article published in the British Journal of Dermatology suggested that simvastatin may be a useful tool against venous ulcers. These are superficial irregular shaped wounds usually around the ankles caused by backed up pressure in the leg veins. The double-blind, placebo-controlled trial included 66 patients with venous insufficiency ulcers treated for up to 10 weeks with simvastatin 40 mg/d or placebo. All patients were also advised to make use of compression and elevation, as well as other standard ulcer therapy during the study.

The Results
Overall, 90% of patients in the simvastatin group experienced wound healing, compared with only 34% of those in the placebo group, and time to healing was faster in the simvastatin group than in the placebo group.

Venous Ulcers and Simvastatin: Outcomes

Further, in patients with ulcers measuring 5 cm or less, 100% in the simvastatin group experienced wound healing, while only 50% in the placebo group did, and 67% of those with ulcers measuring greater than 5 cm in the simvastatin group experienced wound healing compared with 0% in the placebo group.

What’s the “Take-Home”?
The next step for many of these patients would have been surgical treatments, so I think we can celebrate the fact that we have an agent here that we are very familiar with and that is inexpensive that may make a major difference in healing. Whether statins other than simvastatin might work equally well is unknown, but since the dose and expense of simvastatin are accessible to essentially all of our patients, until further data confirm efficacy of other agents, it’s probably best to stick with simvastatin. This is a game changer.

Reference: Evangelista MTP, Casintahan MFA, Villafuerte LL. Simvastatin as a novel therapeutic agent for venous ulcers: a randomized, double-blind, placebo-controlled trial. Br J Dermatol. 2014;170(5):1151-1157.

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Deadly Brazilian Butt Lifts

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In my previous blog Brazilian Butt Lift - Buttock Augmentation Implants and Injections I discussed the history of buttock augmentation, the surgery and illegal buttock injections by untrained individuals leading to loss of life. According to statistics from the American Society for Aesthetic Plastic Surgery (ASAPS) plastic surgeons, dermatologists, and facial plastic surgeons performed 18,487 of these procedures in the US in 2015 compared to 7,382 in 2011, a 150% increase over 4 years. The total from 2011 through 2015 is estimated at over 65,000. If other surgeons are included the 2015 total could have been as high as 23,000 and the 2011 through 2015 numbers as high as 100,000. In 2015 a buttock procedure (fat grafting, buttock implant or buttock lift) was performed in the US every 30 minutes of every day. Now as the procedure becomes increasingly popular with surgeons it has become obvious that this is the mostly deadly procedure performed by plastic and cosmetic surgeons.

To investigate this ASAPS created a task force, which surveyed, queried and interviewed medical malpractice carriers, state medical boards, individual plastic surgeons world wide, American medical examiners and U.S. autopsy reports in July 2016. 25 deaths associated with the procedure were confirmed by individual surgeons and medical examiners over the previous 5 years. 4 deaths were reported between 2014 and 2015 by the American office operating room accreditation entity AAAASF. That translates to 1 death every 2 to 3 months from this procedure. The very first case report of death following buttock fat injection due to fat travelling to the lungs (pulmonary fat embolization-PFE) was published in the pathology literature in 2015. I am also aware of deaths from the procedure due to puncture of large arteries or bowel with the metal tubes used to harvest or inject the fat. The ASAPS task force consisted of 11 surgeons, pathologists, and statisticians who limited their study to the risks of both fatal and nonfatal fat embolization. Most non-fatal fat embolization cases require a stay in the intensive care unit on a ventilator breathing machine and may result in permanent lung impairment.

The queried surgeons accounted for a career total of 198,857 cases. In this group there were 32 fatal and 103 non-fatal fat embolization cases. Over the previous 12 months (July 2015 to July 2016) this group had performed 17,519 cases resulting in 5 fatal and 12 nonfatal pulmonary fat embolization cases. That is almost 1 death every 2 months and 1 case requiring hospitalization in the intensive care unit per month. Surgeon experience i.e. number of cases performed was not statistically related to the number of pulmonary fat embolization cases. About half of the surgeons reported having performed 50 or fewer cases. The technique used/described by the surgeon though was statistically associated with increased risk of having either complication.

Transverse View of the Right Side of the Body at Hip Level

Recent Research in Hidradenitis Suppuritiva

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Antibiotic Therapy for HS Can Induce Antibiotic Resistance
A cross-sectional analysis of 239 patients with HS evaluated from 2010 to 2015 compared use of antibiotics to no antibiotics with respect to the development of bacterial resistance to antibiotics.

Tetracyclines and oral clindamycin were not associated with any significant antimicrobial resistance. Therefore they should be used in preference to Bactrim, Ciprofloxacin and topical Clindamycin to treat HS related infections.
Fischer AH, Haskin A, Okoye GA. Patterns of antimicrobial resistance in lesions of hidradenitis suppurativa. JAAD. 2017;76(2)309-213.e2

Eyelid Surgery and Headaches

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There are different types of headaches including migraine, tension and cluster headaches. The causes of headache are as variable as the proposed treatments. Over the last 5 to 10 years plastic surgery in the treatment of headaches has become increasingly popular. This blog only deals with eyelid surgery and tension headaches.

Upper eyelid surgery can be cosmetic for the removal of excess skin or reconstructive to improve vision by removal of excess skin and/or eyelid ligament tightening . A cohort study of 108 eyelid skin  removal only cosmetic blepharoplasty and 44 reconstructive skin removal with eyelid drooping blepharoptosis procedures (cosmetic and drooping eyelid surgery) treated between September 1, 2014 and September 1, 2015 were compared using Headache Impact Test-6 scores before and after surgery.  The test scores are derived from questionnaires completed by patients. 35% of the skin only blepharoplasty and 64% of the visually impaired patients had tension headaches before surgery. The scores in the first group went from 56 to 46 and in the second group from 60 to 42 following surgery.

The conclusion is more patients with drooping eyelids affecting vision have headaches than patients who just want cosmetic upper eyelid surgery and though both groups have less severe headaches after surgery those whose vision was affected have more improvement. Additionally the more their vision was affected the greater headache severity they had before surgery and the more relief they had after surgery.

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Lentigo Maligna and Lentigo Maligna Melanoma

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Lentigo maligna is a melanoma in situ that forms in sun exposed areas of skin, first described in 1892. Under the microscopic one sees a proliferation of atypical pigment cells in the superficial skin. They typically have a cloud like appearance with variable shades of brown coloring and start as a freckle that enlarges over a number of years. Historically they were called Hutchinson's freckle. More than half occur on the face or neck. They are more common in warmer climates with greater sunlight exposure and the majority occur after the 6th decade of life . If ignored long enough they will develop a vertical growth phase and begin to invade the deeper layers of skin, dermis. They are then malignant melanomas and are called lentigo maligna melanoma. At the time of presentation 10 to 20% of lentigo malignas have already invaded the dermis to some degree. Although melanoma represents a small portion of all skin cancers, it is responsible for the majority of skin cancer–related deaths.

The diagnosis of melanoma of the lentigo maligna subtype is challenging, as the clinical presentation is quite varied, ranging from a subtle brown patch to tan/black or even amelanotic(almost normal skin color). These lesions pose significant treatment challenges for clinicians because of significant invisible to the eye surrounding extension, a predilection for cosmetically and functionally sensitive areas, and a naming system that is often confusing. Obtaining a biopsy specimen from a clinically suspicious lesion can present problems, given the lesions can be as large as 6cm in anatomically and cosmetically sensitive areas. If the suspicious lesion is small, an excisional biopsy of the entire pigmented lesion to fat is recommended. However, an excisional biopsy is rarely feasible, as most lesions are too large with poorly defined margins to be completely removed. In this setting, a small biopsy of the darkest, or most palpable, or otherwise most visibly concerning area of the lesion is recommended.

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.

Breast Implants and Breastfeeding

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Breastfeeding is a vital function for infant mother bonding, transmission of antibodies to the baby to fight infection etc. All women with breast implants and no other prior breast surgery giving birth at an Argentinian hospital between April 2013 and July 2014 were followed and compared to body matched mothers and babies. After giving birth those with breast implants had insignificantly lower success at breastfeeding at 30 days after giving birth than those women who did not have breast implants: 93% with implants vs. 97% without implants. Also, it did not matter whether the implants were placed via incisions in the crease under the breast or in the outer edge of the areola (skin around the nipple). Therefore we can conclude that most women can establish breastfeeding even if they have breast implants irrespective of how the implants were placed.

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Tattoo Removal

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PicoWay tattoo removal laser (Syneron Candela) surveyed 250 people who had one or more tattoos removed and 100 people who were thinking about removing one or more of their tattoos between 9/29/2016 and 10/6/2016. 83% who had a tattoo removed were planning on getting a new tattoo and were more likely to do so because they know they have the option of removing it. 13% of this group had it removed because they had become parents. The most commonly removed tattoos were a person’s name. Symbols and animals came in a close second and third.

The person who removed the tattos was:

 Of the 100 contemplating removal:

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Laser Tattoo Removal Success Rate

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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
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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
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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
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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.

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