Treatment of Vitiligo, Hypopigmentation and Hypopigmented Scars.

Lighter colored (hypopigmented) areas of skin can be due to skin damage with scarring or for unknown reasons. When the cause is unknown the process is called vitiligo and is presumed to be due to an autoimmune phenomenon or a viral infection. Vitiligo affects 1 to 2% of the people in the world, 2 to 5 million in the US alone. Have of these affected people developed it before the age of 20. Regardless of the cause the common factor between all of them is white patches of skin where the skin pigment cells called melanocytes have been killed. If the line width of the area is in the order of a few millimeters application of a tattoo needle without tattoo pigment or application of an excimer laser has corrected the problem. Tattoos have also been employed but this is impractical when the hypopigmented patches are large. Tattooing a skin color into the white patch has not been reliable as the approximation of any given individuals native skin color is very difficult. Of course cover make up has been around for centuries and can provide adequate camouflage but has to be repeatedly applied.

Botox Resistance or Fatigue

Botox resistance or fatigue occurs when the injection does not last as long or is ineffective. If the botox is fresh and effective this can be due to circulating antibodies against Botox formed by the body in response to previous injections or changes in the muscle itself over time.

Zytaze (a zinc and phytase prescription medication) given in oral capsule form 2 capsules a day for 4 days (total 10 capsules) prior to Botox injections to patients who responded poorly to Botox injections improved the effect of the Botox injections or how long they last. It is dispensed as 10 per box. This was studied in patients with uncontrolled eyelid twitching (blepharospasm) treated with Botox but should also hold true for Botox administered solely for cosmetic reasons. The mechanism as to why this supplement would be effective or how it works are not known.



Contraindications to botox injections include pregnancy, breast feeding, allergies to components in the botox (human albumin), neuromuscular disorders (myasthenia gravis, Eaton-Lambert syndrome, amyotrophic lateral sclerosis) and use of medications that strengthen the effect of botox (quinine, calcium channel blockers and aminoglycoside antibiotics).

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Stem Cell Face Lifts

Stem cells are cells that can turn into any one of a number of cell types hence the term pluripotential. Some stem cells can only turn into one of a specific cell type (multipotent, oligopotent etc). The majority of cells in an embryo have not fully differentiated or turned into their final cell type be that a skin, liver, heart or muscle cell. The majority of cells in an adult person have turned into their final cell type. Furthermore that final cell type if it is a dividing cell will only produce more of the same cell type. Stem cells can divided into more stem cells or turn into different types of cells such as skin, muscle etc. Much media exposure has been given to the embryonic stem cells, mostly those that would otherwise be discarded at fertility clinics rather than implanted. This blog is about those stem cells found in an adult human. Apparently many of these stem cells are located in the fat layer that covers the body just under the skin layer and they can be harvested by a simple liposuction procedure. Stem cell treatments have been proposed for everything from spinal cord injuries to stroke, alzheimer's, diabetes, parkinson's, arthritis, organ or limb regeneration etc. The can fix anything including the kitchen sink.

New Botox Available in US in September 2010

A new type of Botox called Xeomin (Merz Pharmaceuticals] will become available in the US in September 2010. The drug was approved by the FDA in August 2010 for treating certain neuromuscular conditions, such as blepharospasm (chronic blinking), cervical dystonia (tight neck muscles that distort the head's position). It is not yet approved for cosmetic purposes to treat dynamic wrinkles between the brows and on the forehead. Such use would be considered off label but Botox was used in such an off label fashion for years before it received FDA approval for cosmetic use.

That means we will now have 3 products available, Botox, Xeomin and Dysport to treat aging wrinkles of the face. More Dysport has to be injected to get the same results as Botox but since the per unit price is cheaper the end cost to achieve a given result is the same for Botox and Dysport. Xeomin is formulated differently in that it does not contain the complex proteins found in the other 2 formulations. It is too early to say if this is a positive or negative attribute. It could lead to migration of the Xeomin away from the injection site with more side effects or it could mean you will not form antibodies or develop resistance to the medication after many injections.

Since the price of Botox did not change after the introduction of Dysport is likely those prices will not change after the introduction of Xeomin. That may be due to Dysport's failure to steal market share from Botox but only time will tell.

Countries where plastic surgery is most popular

The International Society of Aesthetic Plastic Surgery recently conducted a survey and came to the conclusion that the countries where plastic surgery is most popular or the largest number of per capita procedures performed are :
1. United States
2. China
3. Brazil
4. India
5. Mexico
6. Japan
7. South Korea
8. Germany
9. Turkey
10. Spain
11. Argentina
12. Russia
13. Italy
14. France
15. Canada
16. Taiwan
17. United Kingdom
18. Colombia
19. Greece
20. Thailand
21. Australia
22. Venezuela
23. Saudi Arabia
24. Netherlands
25. Portugal

Brazil and China have taken the place of Japan and South Korea in previous surveys. The emerging markets of the world have emerged.

Abdominoplasty - MuscleTightening + Diastasis Repair

This is how much muscle tightening I was able to achieve from this week's abdominoplasty for a mommy makeover.

The placement of the vertical row of sutures is the repair of a diastasis and in doing this repair the abdominal muscles are tightened. In this case I placed an extra horizontal row of sutures at the belly button level to get even more muscle tightening.
Mommy Makeover Surgery - Abdominoplasty
Abdominoplasty - Tummy Tuck
Mommy Makeover Abdominoplasty - Tummy Tuck on Youtube
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Botox Manufacturing Kills Mice

I just found out today that for every batch of botulinum toxin created, tests are performed on laboratory mice. The test employed is the LD 50, that is the dose of botox that kills 50% of the mice it is given to. After the toxin is administered by a needle stick to the belly impaired vision, paralysis and respiratory arrest follow. Those that die suffocate. The process takes three or four days. The surviving mice are then euthanized. It is estimated that worldwide at least 600,000 mice die in the production of botox each year. In the European Union alone, tens of thousands of animals are estimated to be used in this testing per year. As the use of botox increases so does this number. Europe has a ban on animal testing for cosmetics but botox is considered a medical treatment so the ban does not apply. There currently is no other assay available or in use to determine botox strength and doseage in each batch of botox that is manufactured.

July 26, 2011 addendum:
Allergan (the manufacturer of Botox) spent $65 million on more than a decade of research that led to a new animal-free test, testing the effect of Botox on cells in a lab dish. The Food and Drug Administration approved the test in June 2011. Allergan estimates it will be able to reduce its animal testing by 95 percent over the next three years as countries outside the United States approve the new procedure as a replacement for the old LD50 test.

Baby Ear Deformity - Deformed Baby Ear

25% to 35% of babies born in the United States each year are born with an ear deformity. That is 1.5 million babies each year. There are 4 types of ear defects:
1-small or absent ears
2-folded ears also called lop ear where the top of the ear is folded downward or Stahl's ear when the top of the ear is pinched like a Star Trek Vulcan look
3-cup or constricted ear which looks like there is an invisible ring around the ear squeezing it
4-protruding ears that stick out from the sides of the head
Some studies have reported that 70% of ear deformities will either worsen or remain the same over time as the child ages.

#Hidradenitis of the Armpits - Boils Under the Armpits

Inflammation of the armpit glands or #Hidradenitis, was first described by Velpeau in 1839. In 1854, Verneuitt suggested that this condition might arise from the sweat glands of the skin and described the clinical condition which is now recognized as hidradenitis suppuritiva. Since then, hidradenitis surgeons have recommended many forms of treatment for this entity: lotions, vaccines, fever therapy, toxoids, steroids, ultraviolet light, X-rays, antibiotics, and surgery. The disease does not occur before puberty because the apocrine sweat glands do not function at that age. Patients see this as boils under the armpits that swell, drain foul smelling material and then swell again as the cycle starts over again.

Nasojugal crease, tear trough deformity, nasojugal groove, bags under eyes, under eye hollowness

In the young individual the transition between lower eyelid and cheek is imperceptible. The dividing line between these areas in older individuals is the nasojugal crease also called the nasojugal groove (term first used in 1961) or tear trough (term first used in 1969). It is an early sign of aging around the eyes, lending a fatigued and aged appearance to the face. As part of the aging process ligaments that fix facial skin to the underlying facial bones thin and lengthen or stretch, facial bones recede back and facial fat shrinks. This results in the drooping of facial skin and appearance of laugh lines, jowls, nasojugal creases, eyelid bags etc.. The skin within the nasojugal groove or crease becomes thinner and/or darker in color than the slightly lower nose or cheek skin. It can also seem deeper or be more visible if there is protrusion of fat into the lower eyelid. The aging process starts near the nose as the tear trough and progresses outwardly towards the same side ear becoming what is called the palpebromalar groove.


Tear Trough and Palpebromalar Groove Boundaries



Examples of Tear Troughs in Younger Patients Without Protruding Eyelid Fat

Gynecomastia

Gynecomastia means enlargement of the male breast. The definition has nothing to do with what causes the enlargement or what tissue it is composed of. It is most common around puberty & can involve one or both sides of the chest. Most commonly the enlargement is centralized in the breast but occasionally it is not. It is present to some degree in about a third of male population. It appears either early in adolescence or later in the adult years of life and can be very disruptive in the life of a teenager or adult. Working out in the gym, going to the beach and changing in the locker room can become unpleasant ordeals.

Asian Rhinoplasty - AfroAmerican Rhinoplasty

There are 3 main types of noses - Caucasian, Asian or Oriental and African. The Asian nose has characteristics between those of the Caucasian and African. Today one increasingly finds mixed features between these groups as well so some individuals can have a Caucasian tip with an African bridge or vice versa. The most visible difference is the more vertical nostril alignment with a longer strip of skin between the nostrils in the Caucasian nose vs. the Asian or African nose. The Asian and African nasal bridges are flatter and broader than the Caucasian. In some cases the bridge may be so flat that it appears scooped out or ski sloped. The nasal tip skin is usually thicker with a more rounded tip in the Asian and African noses. The thinner nasal tip skin in the Caucasian nose makes the tip cartilages and their shapes more visible on external viewing.


As you can see in the above diagram these differences are due to differences in the skin but mostly due to differences in the underlying bone and cartilage. In Asian and African noses:

Even a dog can benefit from a facelift

As you can see even a dog can benefit from a facelift. This Shar pei required a facelift because the extra folds of skin were damaging the dog's eyes.

This Los Angeles billboard was actually an ad for a Comedy Central television show not a Veterinarian or a Plastic Surgeon

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Axillary Hyperhydrosis Hyperhidrosis - Excessive Armpit Sweating

Excessive seating from the armpits can be very debilitating causing a bad odor, staining of clothing and restriction of social as well as exercise related activities. This problem can also affect the palms of the hands or soles of the feet.

Sweat glands maintain skin surface health and regulate body temperature by supplying water to the skin surfaces for evaporation. Two types of sweat glands are present over human skin, eccrine and apocrine glands. Millions of eccrine glands are distributed throughout the entire body surface and produce a high salt content sweat that is excreted directly onto the skin through an excretory duct. The greatest density of these glands is found in the armpit, palm, and sole of the foot. The apocrine sweat glands are less in number and are distributed over the armpits, around the anus, around the breast nipple complex, and eyebrow regions. In addition to salt, the sweat from these glands contains fat and cholesterol and is excreted indirectly by passing through the shaft of hair follicles. The apocrine gland is 10 times larger than the eccrine gland, and both are present in equal numbers in the armpits. The apocrine glands start secreting at puberty and stop after menopause in women. Overproduction of either gland in the presence of certain skin surface bacteria can produce a bad odor. Clogging of the apocrine glands leads to a condition called hydradenitis suppuritiva with abscesses and draining pus. The treatment for this is surgical removal of the glands together with the damaged skin and then surgical closure of the resulting wound.

Asian Upper Eyelid Surgery - Asian Upper Blepharoplasty

In the caucasian upper eyelid the deeper layers of the eyelid converge 6 to 8mm above the eyelid margin/eyelashes to create a crease (labeled upper lid crease in the diagram above). In the typical asian upper eyelid these layers do not converge so there is no crease. The absence of this convergence allows fat to descend into the eyelid (as noted in the diagram above) giving the puffy look that is seen in some asian eyelids and the no upper eyelid crease appearance.