THE AESTHETIC MEETING (ASAPS)

VANCOUVER, MAY 2012

PART 3:  BODY, A NEW TREATMENT FOR CELLULITE??

Liposuction techniques are numerous, and not one technology is better than the other. Most plastic surgeons agree that the traditional tumescent technique with fat aspiration continues to be highly effective, predictable, and safe. Techniques that use heat to “tighten” skin are showing complications as a result of thermal damage to overlying skin and soft tissue. These include any laser, radiofrequency, or ultrasound- assisted devices. Complications presented at the conference include skin contour irregularities, permanent skin discolorations, burns, and skin scarring. There is still no better alternative to traditional liposuction with respect to results and safety. The skills of the surgeon are the most important factor in obtaining excellent results, not  the equipment or technology being used.

More recently in the media, a new treatment for cellulite, Cellulaze, has been getting a lot of attention as the new cure for cellulite.  So of course, I participated in the conference given by the lead investigator for Cellulaze. Pockets of fat under the skin are normally divided by fibrous septae that are  thick strands that extend from the skin, through the fat, and connect to the underlying muscle layer. Patients who have cellulite, or visible dimpling of the skin have more than average fibrous septae. So far, many treatments and devices have been advertised as effective for cellulite. Some of these include Endermologie, VelaSmooth, Thermage, Triactive, mesotherapy, massage, radiofrequency, laser liposuction, and topical creams. The results of all of these treatments are universally disappointing, with multiple regular treatments required to see subtle improvement, and results that last only a few months at best.  The newest treatment for cellulite is Cellulaze. Cellulaze is an invasive laser treatment, similar to a liposuction procedure, where tumescent numbing fluid is injected under the skin for local anesthesia, and a laser is introduced under the skin in the area to be treated, typically a section on the thighs.  Three passes are made in the area being treated to break the fibrous septae, break up the fat cells in each pocket, and then heat up the underlying skin to thicken and tighten it.  Recovery is similar to a liposuction procedure, with discomfort, bruising, swelling, and numbness for up to 3 months, and the need to wear a compression garment. A study involving 10 patients was presented at the meeting, showing good (not excellent) results at one year after one treatment. The company, Cynosure, says more studies and data are on the way, with good results at 3 years.  The treatment for a small area on the thigh takes 90 minutes, and costs range from $7000-$11,500 per area. My concern is the heat generated by this thermal device can lead to potential uncorrectable complications, especially if this laser technology gets into the hands of non-plastic surgeons, who do not have the tactile sense and knowledge of anatomy to safely perform invasive surgery. Thermal or heat-related complications that can be seen include prolonged swelling, bruising or scar tissue, contour irregularities, permanent skin discoloration, burns, scarring, fluid collections, and damage to deeper structures. I am going to wait until I see more studies with documented long-term results, and proof of minimal risk and safety before I jump on board with this treatment.  Here is a good article on Cellulaze for reference:

http://www.nytimes.com/2012/05/03/fashion/a-new-treatment-zeroes-in-on-cellulite.html?_r=2&adxnnl=1&pagewanted=all&adxnnlx=1336237919-365BO5o2KaotHsWRoFptPg

Massive weight loss patients with excesses of skin in hard to treat areas such as the upper back and upper arms are successfully being managed with upper back lifts or “bra-strap” lifts in women, where back and lateral trunk skin is excised and tightened with scars hidden within the contours of a normally worn bra. Upper arm tightening or brachioplasty surgery  in these patients is being extended into the armpit and along the lateral breast for optimal contours. It was shown, that mini arm-lifts with scars that hide in the armpits do very little in improving arm contours. There is still no alternative short scar or scarless surgery when it comes to skin-tightening procedures in patients with severe skin excess.

Lastly, vaginal rejuvenation is also becoming more popular. It must have to do with grooming trends and this area tends to be more visible? Excess skin can be removed to create more youthful contours below, and fat injections are used to plump up deflated tissues.

As always, I learned a lot at our annual conference and enjoyed catching up with my plastic surgery colleagues across the US.  At Desert Hills Plastic Surgery Center, we are committed to offering our patients the most current treatments and techniques in the field of Plastic and Cosmetic Surgery, while ensuring the efficacy, predictability, and safety of your procedure.

Dr. Hayley Brown MD, FACS

Plastic  Surgeon Las Vegas 

Desert Hills Plastic Surgery Center, Henderson and Las Vegas, Nevada

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VANCOUVER, MAY 2012

PART 2:  BREAST

First of all, we have a new player in the breast implant market, the company Sientra. We had the opportunity to participate in the Sientra launch party and got first hand information on the company; it’s philosophy, manufacturing standards, and business ethic. It was a large turnout of  plastic surgeons and we were all quite impressed. Sientra is the first new company in over 20 years to be able to successfully break into the breast implant market which has been dominated by two companies, Allergan and Mentor. The best thing about Sientra, is their commitment to sell their silicone implants ONLY to board certified plastic surgeons. Unlike Allergan and Mentor, who sell their implants to other specialties such as dentists, ENT, OB/GYN, Family Practice, and other physicians who have no training to perform breast augmentation, Sientra is committed to Plastic Surgeons. This in turn, translates into patient safety, and patients who receive Sientra silicone implants can rest assured that their surgeon is properly trained. In addition, Sientra implants have the best implant warranty available with an automatic lifetime warranty for rupture and $3600 cash funds available for surgery. Sientra’s implants are also the most cohesive, form-stable implants FDA approved in the United States. We are excited to start using Sientra implants!

Breast reconstruction and complicated breast  implant revisions  are being  successfully handled with ADM. ADM stands for Acellular Dermal Matrix, which is essentially a skin type of substitute. Alloderm and Strattice are examples of ADM and are used widely in many applications. This product works well for complicated breast problems including situations of tissue thinning, rippling, and contour problems, where this product is added to an implant pocket to cover, support, and pad an implant. In addition, it can provide support to the periphery of an implant pocket in the situation of implant malposition. Patients who have experienced recurrent capsular contractures may also benefit from the addition of this material, which is substituted for a section of the capsule to break up the scar and maintain breast softness. Because of the high cost of the product, it best serves patients who have had multiple recurrent complications where other techniques have failed. In the situation of breast reconstruction after treatment of breast cancer, insurance companies handle the cost.

Fat transfer is also a safe and effective option in treating breast or body contour depressions. This involves liposuction of an area such as the inner thigh, preparing the fat, and re-injecting it into areas that are deficient. Touch up procedures may be required in  50% of patients as a result of the potential reabsorption and unpredictability in the “take” of the graft.  As an alternative to an implant,  larger volumes of fat can be injected for generalized breast augmentation.  Although results can be subtle because of variable fatty tissue absorption,  we are seeing improved results when simultaneous Brava suction devices are used a few months before the fat transfer procedure. Brava is a breast suction cup type of device, basically a vacuum suction cup that is worn on each breast for at least 12 hours per day, and it causes swelling and improved vascularity to the breast tissue. After a few months of wear, the breast tissue is distended, healthier to accept the fatty tissue grafts, and survival of the newly transplanted tissue is enhanced.

Everyone  is hearing about stem cells, and fatty tissue does contain adult stem cells. The simple transfer of fat is not considered a stem cell procedure. The stem cells need to be isolated and concentrated. There are several techniques of stem cell concentration that are currently under investigation. The benefits of stem cells are assumed, yet we are not quite there yet with scientific data showing proof of stem cell benefits in the field of aesthetic surgery.  We also need to see data proving the safety of these procedures, before they can be offered to prospective patients. Studies are in progress so be patient!

When it comes to silicone breast implants, and silent ruptures, high-resolution ultrasound may become an accurate method in evaluating the integrity of the implant shell, so that MRI’s may not be required. We will have to wait to see how this evolves with respect to the current FDA recommendation for MRI surveillance of silicone breast implants.

Keller funnels are also being used more frequently for silicone implant insertion.  This is a funnel, similar to a cake decorating cone.  This guides the implant into the pocket more easily, so the implant itself has less contact with surrounding skin, theoretically decreasing risks for bacterial contamination of the implant, and potentially decreasing risks for scar tissue to develop around the implant (capsular contracture). Other reported benefits to women include significantly reducing force on the implant shell which can prevent a future rupture, shortening incision lengths, and potentially minimizing post operative bruising and swelling. Keller funnels are being used in our practice.

Part 3 of my report will discuss the newest techniques for Body Contouring…

Dr. Hayley Brown MD, FACS

Breast Augmentation Las Vegas Surgeon

Desert Hills Plastic Surgery Center, Henderson and Las Vegas, Nevada

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THE AESTHETIC MEETING (ASAPS)

Just back from Vancouver! There were about 3,000 participants at the  ASAPS meeting in the Vancouver Convention and Exhibition Centre, which began Thursday, May 3, 2012. Attendees were mostly board certified plastic surgeons from the U.S., with other plastic surgeons from Latin America and Europe. After attending the Scientific Sessions over the weekend, and enjoying the scene at the Fairmont Pacific Rim lobby bar, here is what I came away with:

PART 1:  FACE (FACIAL REJUVENATION)

Facial rejuvenation remains all about volume, the addition of volume to a deflated face using either fat, or any of the other available injectables, such as Juvederm, Restylane, Radiesse, and Sculptra, which are most commonly used. Blunt-tipped cannulas instead of sharp needles are being used for the injections to decrease bruising as well as avoid damage to surrounding blood vessels and nerves.  We will definitely use these in our practice, especially around delicate areas such as the eyes which are prone to bruising. Most injectables are lasting about 1 year. Sculptra can last several years. Fat can last much longer, but reabsorption of fat can be unpredictable, and often patients need touch-up procedures. Fat is generally not recommended around the eyes, as complication rates are high, and lumpiness or visibility  can be difficult to correct. Hyaluronic acid products such as Restlyane and Juvederm are more forgiving, as there is an enzyme called Vitrase (hyaluronidase),  which can  immediately dissolve these products if there is any undesirable effect.

It is also interesting to see that the addition of volume to the face is commonly “overdone” and there is population of patients with overdone fillers that look unnatural and distorted.  As I look around the room during this scientific session, I see several of these people in my vicinity. Also called the Cat-Face, the biggest problem here is too much cheek fillers. If too much is put in, the enlarged cheek presses against the eye, making it look smaller and slanted. Too much filler also gives the face a triangular look: wide at the cheekbones and comparatively narrow at the jaw. In moderation, this is a youthful shape; but in excess, it just adds to the feline quality. So why are people paying for this? The mentality here is, “Why not put in more and look even better?” This emotional response is something I see regularly in women who get breast enlargement–the swelling goes down,  and 9 times out of 10 they want bigger implants.  Its like any addiction– wanting more of what is making them happy. But what happens is that individuals can forget what they used to look like and lose all sense of proportion and reality.

Volume needs to be added naturally in moderation, and done in a subtle manner, especially around the cheeks and lower lids to avoid the “cat face”.  If volume is being used as the primary modality for facial rejuvenation, it must also harmonize with contiguous areas, such as the neck. If the neck is loose and wrinkled alongside a plumped-up pillow face, the whole appearance looks unnatural and discordant. At that point, it is time for a facelift or necklift, and some backing-off of the fillers.

Mini-facelifts continue to be popular, but realize that despite the decreased invasiveness of the procedure, the recovery process can be similar to more aggressive procedures. Bruising and swelling is more a result of an individual’s response to a procedure and is unpredictable, more so than the extent of the procedure. Some patients tend to bruise and swell more, even if they have had a minimally invasive rejuvenative procedure, and they stay home for 2-3 weeks until they feel comfortable in public. Other patients may go through a full face and neck lift, and have relatively mild bruising and swelling, getting back to work comfortably in 7-10 days. Regardless of the nature of the facial surgical procedure, expect 2-3 weeks of relative social inactivity, and sometimes 6 weeks for naturalness. Facelifting is individualized per patient, not one procedure has shown better results than the other. Most patients and physicians expect 6-10 years of longevity in the results for most normal individuals who maintain a healthy lifestyle.

Stay tuned for part 2 and 3 of this blog discussing BREAST AND BODY.

Dr. Hayley Brown MD, FACS

Breast Augmentation Las Vegas Surgeon

Desert Hills Plastic Surgery Center, Henderson and Las Vegas, Nevada

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We are packing our bags and heading to Vancouver for the The 45th Annual Aesthetic (ASAPS) Meeting! The American Society for Aesthetic Plastic Surgery (ASAPS) is the leading professional organization of plastic surgeons certified by the American Board of Plastic Surgery who specialize in cosmetic plastic surgery. ASAPS is at the forefront of innovation in aesthetic plastic surgery around the world. We will keep you posted on the latest and greatest in Plastic Surgery!

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These “new” procedures are flooding the media and Internet as the next best thing in cosmetic surgery.  But are they really new? NO. All of these procedures are simply fat transfer procedures!  These procedures are not new or innovative. Fat transfer procedures have been around since the 80’s, when liposuction became available.  A fat transfer procedure (fat grafting, fat autographs, autologous fat transplantation, fat injecting or microlipoinjection) harvests fat from one part of the body using liposuction techniques and then places it in another part of the body where the fat is used for cosmetic enhancement. Typically the abdomen or thighs are used as the fatty tissue donor site, and the fat harvested is injected into your face, breasts, or buttocks for volume.

Stem cells are present in many tissues of the body, including fat. These cells have the ability to develop into different cell types. They can release growth factors that can assist in the process of healing and regenerating tissues. Standard fat grafting procedures, which naturally transfer some stem cells normally present in the fat, are not “stem cell procedures”. Stem cell procedures need to involve a method to collect and concentrate stem cells.  As to whether stem cells can be activated and concentrated and therefore change the procedure from simple fat grafting to a true stem cell procedure is unclear.  The Food and Drug Administration has not approved the use of any stem cell activating agents or devices, and large-scale studies have not been conducted to prove either effectiveness or safety.  So if your stem cells could be concentrated and reinjected, we have no evidence that your result would be better or longer lasting.

What are the risks associated with Fat Transfer and Stem cell procedures? Because stem cell procedures do not have FDA approval, the full risks are unknown.  The main problem with fat injection procedures is the unpredictability in the result. Depending on the surgeon, the patient, and several other factors, the body is reported to reabsorb anywhere from 20 to 95 percent of transferred fat. Generally, 40-60% of the transferred fat can persist permanently. However, results are extremely technique dependent and variable. So be comfortable with a lack of permanence in the results and potentially needing a touch up procedure to maintain the result.  Other risks associated with these procedures include undercorrection, overcorrection, contour irregularities, bruising, swelling, redness, infection, sensation change, lumpiness or firmness and general dissatisfaction with the end result.

The American Society for Aesthetic Plastic Surgery (ASAPS) and The American Society of Plastic Surgeons(ASPS) position on this issue is as follows:  “The marketing and promotion of stem cell procedures in aesthetic surgery is not adequately supported by clinical evidence at this time. Extreme caution should be exercised when a physician is promising results from any treatment that sound too good to be true.”

I do believe that stem cells may offer beneficial medical therapies both in the field of plastic surgery and in treating disease. I banked my baby’s umbilical cord blood and tissue, for the benefit of having access to both the lifesaving qualities of cord blood and the potential future uses of cord tissue that are in research stages. As for cosmetic surgical procedures using stem cells,  right now, there is no scientific proof that stem cell procedures are safe and effective, and really do what the marketing claims advertise. As with umbilical cord tissue, we are still very early in the research stages.  Fat transfer procedures will always have a role in cosmetic surgery. Fatty tissue is one of most well tolerated fillers available to aesthetic surgeons, and thus has broad applications. It is natural appearing, lasts a long time, and is safe. It is an effective filler used for changing body contour, revising scars, filling depressions created by liposuction, and rejuvenating the hands and face.

Dr. Hayley Brown MD, FACS

Las Vegas Breast Augmentation Surgeon

Desert Hills Plastic Surgery Center, Henderson and Las Vegas, Nevada

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Every year The American Society for Aesthetic Plastic Surgery (ASAPS) sends each one of us Board Certified Plastic Surgeons a questionnaire to assess our case numbers for the year. The results are in for this year– Almost 9.2 million cosmetic surgical and nonsurgical procedures were performed in the United States in 2011. From 2010-2011, there was a 1% increase in the total number of cosmetic surgical procedures. Our practice volume was up 5% from 2010. Hopefully this reflects some improvement in the economy.

The top five surgical procedures were:

Liposuction (325,332 procedures)

Breast augmentation (316,848 procedures)

Abdominoplasty (149,410 procedures)

Eyelid Surgery (147,540 procedures)

Breast Lift (127,054 procedures)

For the first time in 3 years, Liposuction surpassed breast augmentation as the most common cosmetic procedure in the United States.

The top five minimally invasive procedures were:

Botulinum Toxin Type A (2,619,739 procedures)

Hyaluronic acid, such as Juvederm and Restylane (1,206,186 procedures)

Laser Hair Removal (919,802 procedures)

Microdermabrasion (499,427 procedures)

IPL Laser Treatment (439,161 procedures)

I would anticipate continued growth in our number of cosmetic surgical procedures over this next year as our economy continues to slowly improve. People have been putting off procedures and are at the point where they are ready to invest time and money into themselves.  With respect to facial rejuvenation, minimally invasive procedures such as Botox and soft tissue fillers only go so far.  I anticipate more facelifts, brow lifts, and eyelid surgery in our practice this next year. As you age and gravity takes over, surgical procedures that lift the skin and reshape the underlying tissues are necessary in order to show significant improvement. Also, surgical procedures done sooner have better longevity because of better skin tone and elasticity the younger you are. Facial cosmetic surgery performed earlier in life may have more natural results, as the enhancement is subtle.  Dramatic changes done later in life may be harder to hide without explaining that you had a facelift. It’s all about maintenance and continuing to look youthful and fit as you pass through middle age and beyond.

Our silicone breast augmentation numbers have also continued to increase relative to saline breast augmentation, as the population has become more confident in the device and it’s safety, while preferring the more natural feel of silicone breast implants over saline implants. A new manufacturer of silicone breast implants, Sientra, just got FDA approval, so now there are three FDA-approved silicone gel-filled breast implants in the U.S. manufactured by Allergan, Mentor, and Sientra. Both physicians and consumers now have more available options of FDA approved silicone implants than ever before.

Dr. Hayley Brown MD, FACS

Las Vegas Breast Augmentation Surgeon

Desert Hills Plastic Surgery Center, Henderson and Las Vegas, Nevada

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Why does everyone want to put Vitamin E, Neosporin, or Mederma on their scars?

The Vitamin E myth has been passed down from generation to generation, and the Mederma and Neosporin marketing teams are doing a fabulous job.

Despite all the great ads and commercials for Mederma-IT HAS NO PROVEN BENEFIT for improving scars.  Do you know what Mederma is? Onion extract!  The manufacturer recommends you apply it three times a day for 8 weeks. Did you know that if you apply lotion or Vaseline on a scar three times per day and 8 weeks pass, your scar would look better than if you use Mederma? Three major controlled scientific studies have shown this!  Save your money.

Now, what about Vitamin E? Vitamin E is an antioxidant and has anti-inflammatory effects, and adversely affects platelet function.  (So be sure and stop Vitamin E supplements before a surgical procedure as it can increase your risk for bleeding) Scientific studies have shown that there is no benefit in scar quality by twice per day application of Vitamin E compared to Vaseline or Aquaphor. As a matter of fact, the scars can look worse due to the high risk (30%) of allergic contact dermatitis, which causes a horrible rash and inflammation affecting the healing scar.

Neosporin is the most heavily advertised and most popular topical antibiotic in the country. It has three active antibiotic ingredients in a petroleum jelly base: neomycin, polysporin, and bacitracin. “Triple Antibiotic” has the same ingredients. Both products are sold over-the counter. Immediately after a surgical procedure or injury, Neosporin will speed healing while reducing infection rates and scaring. But you need to stop using it once the wound is closed and healed. The problem is that about 25% of patients who continue to use the product will develop ‘contact dermatitis’, usually from the Neomycin component in the product. The rash and reaction from allergic contact dermatitis can range from mild to severe. I have seen several cases of severe reactions to Neosporin with resulting rash and inflammation to the scar and surrounding skin, having a deleterious effect on the final scar. I even had one patient in my practice end up in the emergency room with a severe allergic reaction requiring hospitalization and  IV steroids.  These patients subsequently required scar revisions.  I do frequently recommend topical antibiotic ointment for the first 1-2 weeks or so after a procedure, however I recommend that the product is discontinued once the incision is completely healed and for users to monitor for signs of a rash, redness, or itching which would require immediate cessation of the product.

Conclusion:  DO NOT USE VITAMIN E OR MEDERMA on your scars. Do not feel the need to self-treat. In the majority of patients, the best course of action is keeping the incision clean and moist. After incisional healing, lotion or Vaseline, keeping the scar soft and supple will provide you with the best quality scar. I advise Cetaphil lotion,  Aquaphor or Vaseline, which is well tolerated by patients with low risks of allergic reactions, rashes, or breakouts.

Here’s what works in reducing the appearance of scars:

1.   Hydration. It is widely recognized that wounds heal best under moist conditions — the skin fills in faster and scars are less visible. So after complete incisional healing, in 1-2 weeks, I recommend Cetaphil lotion to keep the scar soft and supple. Aquaphor or petroleum jelly is fine too. But beware of too moist… to avoid maceration of tissue and infections. It’s a fine line!

2.   Massage also helps in softening and smoothing scar tissue.

3.   Sunscreen is required to prevent darkening and persistent redness of scars. It should be used for at least one year on sun-exposed scars. Scars and surrounding skin after a surgical procedure can be very sensitive and can burn during the normal Las Vegas summer temperatures. Avoid black clothing or swimwear when spending significant time outside in the summer to avoid the absorption of too much heat that can burn sensitive skin, and redden scars.

4.   Silicone Gel Sheeting.  Silicone sheeting is available at my office or over-the-counter. Neosporin scar strips are silicone sheets.  Consistent use of this product has been proven to improve scar quality. This is the only over-the-counter scar therapy that works. The mechanism by which it works is unclear, but we think it is a combination of pressure, hydration of the scar, and a change in the electromagnetic energy within the scar. The problem with this product, however, is compliance. For the product to be effective, the silicone sheet needs to worn on the scar the majority of the time for months.

5.   Pressure. Pressure may theoretically break up collagen bundles and soften the scar mass; however, therapy must be instituted for long periods (>23 h/d for 6 mo) before significant effect can be achieved. Burn scars are typically treated with pressure garments.

6.   Bleaching creams. In  patients predisposed to pigmentation of scars, I  preventatively prescribe hydroquinone. This is a topical bleaching cream that needs to be applied twice per day to dark scars. Regular compliance is required for it to work, and it may take 4-6 months to see improvements, together with strict sun avoidance on the area being treated.

7.   Steroid Injections are effective in treated hypertrophic and some keloid scars. I monitor all patients in my office until their scars are mature. Usually at around 6 weeks after surgery, the scar is the reddest and most inflamed. Patients with potential to form hypertrophic scars usually declare themselves at this time. A series of Kenalog (steroid) injections performed once every 6 weeks is usually an effective treatment for raised, thick, ropey scars. These scars can be tender and itchy as they secrete histamine, so over-the-counter antihistamines such as Benadryl can also help symptoms.

What about old or mature scars?

The treatments mentioned above are for immature scars, scars that are in the process of healing and remodeling. Usually after 1 year or longer, when the pinkness of the scar is resolved, the scar’s appearance is permanent. Here are options for improving scar quality in mature scars:

1. Surgery. Surgical scar revisions DO NOT remove scars. Plastic surgeons perform surgical scar revision to alter its size, make in narrower,  reorient it so that it lies along natural skin folds and tension lines, and to improve upon depth and irregular texture.  Surgery for hypertrophic or keloid scars has a very high risk for recurrence. Since the recurrence rate with surgical excision alone in keloid scars is about 50%, surgical excision is usually combined with one or more of the other listed techniques.

2. Injectible fillers. Injecting substances such as Juvederm or fat can immediately raise sunken scars. However, this treatment doesn’t last permanently and may need to be repeated.

3. Dermabrasion. This procedure uses special equipment to remove the surface of the skin, helping to reduce the look of raised scars. Basically you sand down the skin so it is more level. It works best on the face, but results can be subtle.

4. Laser resurfacing. This is done two ways: The skin surface is removed with lasers, or lasers are used to work on the collagen in the dermis without removing the upper layer of skin.

•      Non-ablative lasers such as the 585 nm Pulsed dye laser, 1064 nm and 1320 nm Nd:YAG, or the 1540 nm Er:Glass are used as the standard laser therapy for hypertrophic scars and keloids.[34] This therapy smoothes the skin by heating up and redistributing collagen while avoiding damage to the epidermis via contact cooling. Multiple sessions are usually required for a significant reduction in redness and improvement in the texture and pliability of hypertrophic scars and keloids. Treatments are expensive and results can be subtle. Lasers may help with scar color including redness or darkness of a scar.

•      Ablative lasers such as the carbon dioxide laser or Er:YAG offer the best results for atrophic and acne scars.[35] Like dermabrasion, ablative lasers work by destroying the epidermis to a certain depth. Healing times for ablative therapy are much longer and the risk profile is greater compared to non-ablative therapy; however, non-ablative therapy is also very expensive, and despite the downtime associated with recovery, offers only minor improvements in cosmetic appearance of atrophic and acne scars.[34

Conclusions:

So here is my opinion when it comes to scars and their treatment…First of all, ensure meticulous incisional closure by a board certified plastic surgeon. Second, keep the scar moist while it is healing. Neosporin is fine for the first 1-2 weeks but monitor for allergic reactions. If you have a history of a Neosporin allergy, there are alternative topical antibacterial creams you can use such as Bacitracin, Bactroban, or Silvadene. Once the incision is completely healed, switch to an emollient  lotion such as Cetaphil, Aquaphor, or Vaseline. Massage regularly. For patients prone to raised or hypertrophic scars, use silicone sheeting or a topical silicone product regularly. For patients prone to pigmented scars, use prescribed hydroquinone bleaching creams. Follow up with me in the office regularly until your scars are mature. I will advise you on the best treatments for your healing scar and will start Kenalog injections or steroids if indicated. Use sunscreen and avoid sun-exposure on healing scars. BE PATIENT! As time passes, the scar will continue to improve! Avoid the temptation to self-treat your scar because you saw a great commercial on TV, or your mother said to use Vitamin E. Lastly, STAY HEALTHY AND AVOID SMOKING. Good nutrition is important for wound healing, and smoking has incredibly deleterious effects on wound healing and scar quality!

Dr. Hayley Brown MD, FACS

Las Vegas Plastic Surgeon

Desert Hills Plastic Surgery Center, Henderson and Las Vegas, Nevada

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This is one of a two-part blog discussing scars.  This first part discusses scar types and the second part will discuss scar therapies. There seems to be a lot of confusion amongst the general public regarding scars, why and when they occur, and how they are treated. When I first started private practice, 12 years ago, I took emergency room call on a regular basis. I would get called at all hours of the day and night to repair lacerations, dog bites, and many other major soft tissue and bony injuries. I would get this call from the emergency room on a regular basis:  “Dr. Brown, a patient is requesting you to come to the emergency room to sew up their laceration so that they will not have a scar.” Similarly, during cosmetic consultations with prospective patients, I am bewildered when a patient is surprised to learn that a scar will result from surgical intervention.  With this blog, I hope to clarify some common misconceptions about scars and scar treatments.

Scars

Scars are the result of surgical intervention or injury. There is no way around it. Scars will result from surgery and scars are permanent. There is no such thing as “scar-less surgery”. Stretch marks are considered scars and are permanent. When scars are fresh, they are red, and over time they fade to a more natural skin color. Scar maturation refers to the time it takes for a scar to fade and soften to reach its’ final quality after going through all the stages of wound healing and collagen remodeling. Collagen remodeling involves a balance between formation and destruction, which occurs during normal wound healing. In most individuals this process takes 12-18 months, but could take longer. The bottom line is that scar appearance improves with time.  All individuals heal differently and form a unique type of scar consistent with their inherent healing ability. Some individuals form scars that are of excellent quality, meaning they are barely seen. Others form more visible scars.

Plastic surgeons are specialists at skin and soft tissue closure, understanding anatomy, skin tension, and tissue movement like no other. We are experts in hiding scars in natural creases and shadows of anatomic lines, while minimizing tension forces on healing incisions.  We obtain inconspicuous scars by meticulous repair, minimizing scar lengths wherever possible.  I always prefer least invasive modalities for intervention while optimizing contours and appearance.

There seems to be a great deal of confusion about keloid scars. I will always ask prospective patients if they have a history of poor scars or keloids. When a patient tells me they have a keloid scar, the majority of the time, it is not a true keloid.

Keloid Scars are scars that enlarge and spread beyond the borders of the initial wound. They outgrow the site of the injury or scar similar to a tumor, but they are benign. They are more common in African-American, Asian, and darker skinned patients but can occur in patients of any race. They are most common on the central chest, shoulders, and earlobes. In my practice, true keloid formers are actually quite rare. I have only a handful of patients with keloid scars and we know each other quite well. No one really knows why keloids form, and there is no definitive treatment. Treatment is incredibly frustrating, as they often recur and do not tend to improve with time on their own.

Hypertrophic Scars are much more common.  If a patient describes a history of poor scarring, this is usually the culprit. These are scars that become raised, ropey,  and red, and often have localized symptoms such as tenderness and itching. They do not enlarge beyond the limits of the scar. They usually begin to develop about 4-6 weeks after surgery and can fluctuate over time, with exacerbations and improvements until the scar matures.

Pigmented Scars or dark scars are also occasionally seen. Basically, the scar becomes darker than surrounding skin as a result of inflammation, which stimulates melanocytes to secrete melanin, which tans the skin. I see this more frequently in darker skinned patients.

Hypopigmented Scars or white scars can be lighter than your surrounding skin. This occurs because the melanin producing cells can’t penetrate the scar.

Atrophic (depressed) or widened scars can occur because of tension, or thinned-out underlying tissues. Certain individuals may be prone to depressed or thinned out scars during collagen remodeling where collagen destruction slightly outweighs its formation.

Stay tuned to part two of this blog that will discuss scar treatments…

Dr. Hayley Brown MD, FACS

Las Vegas Plastic Surgeon

Desert Hills Plastic Surgery Center, Henderson and Las Vegas, Nevada

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I have a very large cosmetic breast surgery practice in Henderson and Las Vegas, Nevada. I specialize in breast augmentation with implants, breast lift surgery, breast lift with augmentation or also called Augmentation-Mastopexy, and Breast Reduction. Basically, women want what they don’t have. Most women with a natural B cup bra size or larger will naturally and expectedly sag at some point. GRAVITY. There is no escaping it.

It always is interesting to hear a woman describe her appearance. Perceptions of one’s self are across the board so to speak.  I always ask patients on an initial consult if they have breast sagging and whether or not it is an issue for them. Some patients explain how incredibly saggy they are, and then upon examining them, the breasts are perky and high. Other women swear that their breasts are not sagging AT ALL, and upon examination we see that their breasts are pancakes hanging to the level of the belly button.  Regardless, women of all shapes and sizes present to my office for breast contouring surgery. Most patients are intelligent, well spoken, and many are professionals or busy mothers. So I don’t understand why there is this common misconception that breast implants treat sagging. The larger, the better. How would a large breast implant be expected to defy gravity and lift a breast? Magic? Breast implants ADD volume and INCREASE bra cup size. The increased weight would pull things down, correct?

Here is a typical scenario: Smart, intelligent, attractive female comes in for consultation to treat breast sagging. She is a natural 34 D bra and does not want to be larger, if anything, wouldn’t mind being a bit smaller. I discuss breast lift surgery and she is confused. “No, I think I need a breast implant. I really want a breast implant.” Really? But if I heard you correctly, you didn’t want to go from a 34 D to a 34 F?

Let me clarify: Breast implants DO NOT treat sagging. They DO NOT lift a breast. They DO NOT defy gravity. Gravity always wins. Breast implants increase cup size, not just a little, but a lot. At least one cup size or larger.  Think of 200 cc as one cup size. Practicing in Las Vegas, I can’t remember the last time I used a 200 cc implant. (My most common implant size range is 350-400 cc, which creates a roughly full C/ small D bra size in a relatively small-chested woman)

Larger breasts are heavier. Larger breasts will sag more. This is normal physics, laws of nature. So I don’t understand why the concept is so confusing?

Breast lift surgery (Mastopexy) surgery treats sagging! Keeping the breast size normally proportioned or slightly smaller will increase the longevity of the lift results. Decisions to increase breast size with the addition of an implant can lead to recurrent sagging over time. This is normal and expected. We will never win the battle with gravity. If your breast is large enough, you neither need nor should want an implant. Not only is it expensive, but also it adds a realm of unpredictability, a future of maintenance surgery for potential ruptures, and in the end aggravates sagging.

Women almost never regret breast lift surgery and wish their old saggy breasts back. But there are many women who regret their decision to add a breast implant, when in the future they have to deal with large, saggy, and stretched-out breasts. It certainly keeps us plastic surgeons busy.

There are many women who are small breasted and sagging and do require an implant for volume, shape, and bra cup size increases. Breast lift with implants is a commonly performed procedure with excellent results in these individuals. Also termed Augmentation-Mastopexy, silicone or saline breast implants are typically placed under the chest muscles and a simultaneous breast lift is performed. The results are gratifying, long lasting, and life-changing in these individuals.

Hayley Brown MD, FACS

Desert Hills Plastic Surgery Center, Henderson and Las Vegas, Nevada

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Would you have your landscaper build your house? I was doing surgery the other day at my usual fully accredited outpatient surgical facility, and found it remarkable that an ENT surgeon next door was doing a breast augmentation!  What woman in their right mind would have an ENT surgeon do their breast augmentation?

The problem is that it is very confusing for the average person to understand how to find a well-qualified surgeon.  Sadly, any doctor can call himself or herself “Board Certified” or a “Plastic or Cosmetic Surgeon”. A frightening number of physicians who call themselves “plastic surgeons” or “cosmetic surgeons” have actually trained in a nonsurgical specialty, and have no formal training in surgery. Many physicians who claim to be “board certified” have not been board certified by the by the American Board of Medical Specialties (ABMS).  The American Board of Plastic Surgery (www.abplsurg.org) is the ONLY Board in the field of Plastic and Cosmetic surgery recognized by the American Board of Medical Specialties.  Attending a weekend course to learn breast augmentation is not enough to be able to perform safe surgery on a person’s chest, and be able to handle potential intra-operative and post-operative complications. There is no way to fully understand the anatomy of the chest without significant surgical training in the chest! Surgery by untrained physicians can be deadly. I completed 4 years of General Surgery training followed by 2 years of Plastic and Reconstructive Surgery training in order to be qualified to perform breast augmentation surgery! And, I would NEVER decide to do orthopedic surgery like a total knee replacement, for example, after a weekend course because the pay was good! How do people sleep at night?

It is critical that patients do their homework to make sure that their physician is Board Certified by The American Board of Plastic Surgery. This is the only board that certifies physicians in plastic surgery of the ENTIRE body, including the face, breast, abdomen, and extremities.  For me to become certified by the ABPS, I was required to possess a five-year college degree and a four-year degree from an accredited medical school. It was mandatory for me to successfully complete a four-year surgical internship and residency, and complete a two-year accredited residency specifically in Plastic and Reconstructive Surgery. That is 15 years of training! And that was still not enough! Additionally, I had to practice plastic surgery for at least two years, submit all of my operative cases for review, pass extensive oral and written exams, receive comprehensive outstanding hospital reviews, before I was even considered for Board Certification in Plastic Surgery. Now that I have been Board Certified in Plastic Surgery for over 12 years, I have more recently completed my ten-year recertification, which requires exams, peer and hospital reviews, in addition to a thorough analysis of my operative cases, and in-depth medical education in my field.

If a doctor says he or she is “Board Certified”, it is in your best interest to check and see by which Board. There is no recognized Board of “Cosmetic Surgery” or anything other than the 24 listed specialties on the ABMS website (www.abms.org).

You should ALWAYS choose a Board Certified physician so that you can rest assured that your doctor has the knowledge, experience, and skills to provide quality healthcare within a given specialty. The Joint Commission, National Committee for Quality Assurance, health care institutions, hospitals, insurers, physicians and patients use Board Certification by an ABMS Member Board as an essential tool to assess physician credentials within a given medical specialty. In addition, Board Certified physicians keep pace with the latest medical advances, which translates into higher standards and the best quality of care.

One more thing:  you need to ask if your doctor has hospital privileges to perform the particular surgery you are interested in. Properly trained and board certified plastic surgeons must have hospital privileges at accredited hospitals. You should ask about your plastic surgeon’s credentials and hospital privileges BEFORE undergoing any treatment or surgery.  It takes 2 minutes to check online for yourself. Hospitals grant doctors privileges to do procedures that fit under their training guidelines. No hospital would grant an ENT surgeon hospital privileges to perform breast augmentation!

Hope that helps!

Dr.Hayley Brown MD, FACS
Desert Hills Plastic Surgery Center, Henderson and Las Vegas, Nevada

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