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.