Skin Necrosis with Dermal Fillers

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The skin necrosis after dermal filler injection is due to direct injection into an artery or compression of an artery by the filler preventing blood flow. This is the only reference I could find "The most serious side effect is localized tissue necrosis, which is induced by mechanical interruption of local vascularity, though it occurs very rarely (nine in 10,000 patients who underwent collagen implantation)". This was a review of collagen fillers done some years ago. When injected with proper technique the incidence should be zero. Certain areas like the area between the eyebrows are at higher risk because of the architectural layout of the blood vessels under the skin. The incidence of heart attack from injection of a skin filler should be close to zero.

The most import thing besides proper injection technique is that if you experience inappropriate pain after filler injection and/or see significant skin discoloration beyond a little bruising your doctor needs to go into emergency mode. That could involve application of nitropaste to the skin surface, application of warmth, injection of a filler dissovling agent, hyperbaric oxygen etc. All of these modalities will minimize the amount of skin necrosis.

With appropriate care and some luck the skin necrosis will be very superficial and heal without visible scarring as in these photos.

Addendum December 13, 2012:
A recent survey of British Association of Aesthetic Plastic Surgeons members found that 69 percent of surgeons reported seeing patients with complications from temporary fillers in the previous 12 months. 49 percent reported seeing patients with complications due to semi- or permanent fillers. More than half of the surgeons saw 1 to 3 patients with these problems in the previous 12 months. Some saw 4 to 6 patients with these complications. The majority of patients seen with semi- or permanent filler complications required corrective surgery or had an irreversible complication. These same surgeons felt the complications were due to incorrect administration by unqualified practitioners.

 Addendum May 28, 2015:
After reviewing information suggesting unintentional injection of soft tissue fillers into blood vessels in the face can result in rare, but serious side effects the FDA issued an alert to health care providers and consumers that unintentional injection into blood vessels can block those blood vessels and restrict blood supply to tissues. Sometimes this can result in embolization where the filler material has traveled to other parts of the body causing vision impairment, blindness, stroke and damage and/or death of the skin (necrosis) and underlying facial structures. 
Their recommendations for consumers were:

• Before deciding to have soft tissue filler injections, talk with your health care provider about appropriate treatment of injection sites and the risks associated with the procedure.
• Be aware that FDA reviewed and approved different products for use in certain areas of the face. The FDA may not have reviewed the use of certain soft tissue fillers for all locations in the body.
• Ask your health care provider about their training and experience injecting soft tissue fillers in the face.
• Read and discuss the patient labeling for the specific filler you are receiving. Your doctor can provide this information, or you can find it on the FDA’s website.
• Seek immediate medical attention if you develop symptoms such as unusual pain, vision changes, a white appearance of skin near the injection site, or any signs of a stroke (including sudden difficulty speaking, numbness or weakness in your face, arms, or legs, difficulty walking, face drooping, severe headache, dizziness, or confusion) during or shortly after the procedure.

Radiesse injectable dermal filler for nasolabial folds
Injectable Fillers - Collagen, Restylane et al
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Skin Bleaching

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In many countries worldwide including the Philippines, India and South America, lightening your entire face or large areas of your body is a common goal to make one's self more competitive in the marriage or job market. A lighter complexion is often seen as a way to climb up the social ladder, make new contacts, find a spouse, get a job etc.


In late 2009 Dominican-born Chicago Cubs baseball player Sammy Sosa showed up at the Latin Grammies with skin lightened by several shades. Sosa admitted to using creams to lighten his skin as well as getting bleaching treatments.

The drooping nasal tip - drooping tip of the nose

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Drooping nasal tip is a term used to describe downward movement of the nasal tip with smiling. More severe forms of this include shortening of the upper lip with the appearance of a horizontal crease and elevation of the outer lower edge of the nostril in the same motion.
Drooping Nasal Tip With Upper Lip Shortening and Horizontal Crease on Smiling
This appearance is created by the actions of the levator labii superioris alaeque nasi and depressor septi nasi muscles.

>Muscles That Cause Drooping Nasal Tip

The treatment is to prevent the actions of the muscles. This is achieved by cutting the depressor septi nasi via an incision in the floor of the nose or the inside of the lip and transecting the outer portion of the tip cartilage with a portion of levator labii superioris alaeque nasi so that it can no longer raise the outer lower edge of the nostril.


The commonly performed trimming of the tip cartilage also helps to rotate the tip upward.

Rhinoplasty
Correction of the Pinched Nasal Tip
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Treatment of Vitiligo, Hypopigmentation and Hypopigmented Scars.

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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

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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

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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

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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

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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

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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

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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.