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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310-246-0537 Dr. Aaron Stone - Plastic Surgeon Los Angeles
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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