Ear Pinning - Otoplasty

August 10, 2014, 11:31 am

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Prominent ears can be socially traumatic for children in their early school years.
It is sad that we have non-surgical ways to treat this in infants using the EarWell so they never have to go through this type of bullying yet many parents do not have their babies treated.

The surgical treatment in children or adults involves making an incision behind the ear and placing shaping sutures in the cartilage to create the missing fold that makes the ear stick out. Over the course of a month or two the cartilage reshapes itself to the shape held by the sutures so they are no longer necessary, though we do not usually go back to take them out. Depending on surgeon preference sutures are placed between the cartilage and the side of the head, skin may be removed from behind the ear and/or some ear cartilage is removed to obtain the best longest lasting ear shape.

Before and After Ear Pinning Otoplasty

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Lipedema, Lymphedema and Fat Legs

February 7, 2015, 10:55 pm

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The 4 main causes for enlarging leg girth or circumference are lipedema (accumulation of fat in the legs), lymphedema (obstruction of lymph flow in the leg), obesity and impaired venous blood circulation (venous stasis). Lymphedema is observed as swelling that usually involves the feet and shows up as impaired flow on lymphangiograms or lymphoscintigraphy . With time the swelling becomes hard and uncompressible and the skin breaks down and becomes infected. Impaired venous circulation is observed as swelling with brown darkening of the skin color, skin break down and inflammation. The blocked veins are visualized by doppler sonography studies using sound waves transmitted through the skin. This blog will focus on lipedema also known as lipoedema in Europe.

The areas of fat concentration tend to be abdominal in aging men, hips and thighs in aging women and buttocks in certain races as those individuals age. The age at which this occurs varies from person to person. Changes in metabolism and fat deposition can also occur more quickly at puberty, after childbirth, gynecologic surgery, with the onset of thyroid disease or menopause. It is easier to lose fat from areas in which your body tends to not concentrate fat. The fat doesn't go to one place and then another as in first, second etc.. It goes all over but more of it is stored in specific areas and it is mobilized from other areas more easily. In some cases the concentration can be dramatic such as very large buttocks with skinny arms and legs, steatopygia, which is more common in certain African tribes.

In some Caucasians, predominantly of European decent, the concentration can be greatest in the upper arms and thighs or entire legs and has come to be known as lipedema. It can be very hard to lose the fat in these areas of high concentration by weight loss diets.

Lipedema is characterized by being almost exclusively in women, it can be inherited, it occurs independent of weight (but obesity is an important risk factor for its severity and prognosis), it is symmetric bilaterally with visible sharp demarcations of fat accumulation vs. nonaccumulation at the ankles, elbows and or waist, it does not diminish with limb elevation, it cannot be diminished by diet or exercise due the high fat concentrating abilities of hyperplastic fat deposits and it spares the feet and hands. In the early stages the legs can seem disproportionately large compared to the rest of the body.

Comparing fat in a leg with lipedema vs. a leg with normal fat under the microscope we see more fat cells per square inch, cells that are more round and more purple staining material between the fat cells. That material consists of inflammatory and scar cells and the substances produced by those cells.

Aids for making the correct diagnosis are (duplex) sonography to rule out venous stasis or thrombosis, the waist-hip index or the waist-height index and lymphoscintigraphy to rule out lymphedema. None of which were documented or performed in this patient. It is unclear if lipedema is just early lymphedema or a cause of later lymphedema. Some believe that the lipedema process affects nerves and blood vessels as well as lymphatics thereby being a cause of chronic pain, easy bruising and progressively restricted mobility. The pathophysiology of that is unclear as diminished use of a limb alone can cause chronic pain syndromes. The mixing of lymphedema and lipedema patients in many published treatment studies invalidates their conclusions. There is no data to support the treating of lipedema over or before obesity in those patients who have both.

The severity of lipedema is staged as

stage 1-fat accumulation with smooth skin surface contour
stage 2-fat accumulation with uneven or pitted skin surface as seen with cellulite
stage 3-fat accumulation into distinct lumps with the formation of folds of skin

Stage 1 with demarcation or band where fat accumulation stops at the ankles

Stage 1 Lipedema

At the more severe Stage 3 the weight distribution when standing becomes concentrated on the inner half of the foot and the below knee part of the leg splays outward leading to ankle and knee joint problems.

Altered weight distribution

The symptom-based therapy of lipedema consists of conservative (compression, complex decongestive physiotherapy, manual lymphatic drainage, exercise) and surgical treatments (liposuction) but there is no cure. Some favor water assisted liposuction while others favor laser assisted liposuction. This is basically the same treatment protocol employed for lymphedema and just like lymphedema the surgical treatment is only medically necessary in more advanced cases after complete evaluation and treatment of other contributing factors.

Cellulite - Cottage Cheese Thighs
Various Forms of Liposuction
Love Handles Liposuction
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Plastic Surgery Rehabilitates Criminals

May 26, 2015, 4:12 pm

≫ Next: Body Dysmorphic Disorder - BDD and Plastic Surgery

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Between 1953 and the early 1960's Dr. Edward Lewison performed free plastic surgery on inmates of the Okalla prison in Burnaby, BC Canada. It was renamed Lower Mainland Regional Correctional Centre in 1970. The study involved 450 prisoners and was undertaken with the cooperation of Dr. Guy Richmond, the prison doctor, and Hugh Christie, the warden. Dr. Lewison and a sociologist chose patients on the basis of a connection between a "bodily defect" and the inmate's behaviour. The idea was that reconstructive surgery that removed deformities would provide such a boost to the prisoners' self-esteem and confidence that they would be motivated to pursue law-abiding lives upon their release from prison. Most of the operations were for congenitally deformed or fractured noses. The rest were for reconstruction of deformed ears, receding chins and removal of facial scars. Almost immediately after surgery, the inmates' behavior improved. "Formerly hostile and incorrigible individuals became polite and gracious in their manner … Among them a keen ambition developed to learn a trade and qualify for transfer to the vocational correctional centre." The studies results were published in the Canadian Medical Association Journal in 1965 citing a 42 per cent recidivism rate for the plastic surgery patients vs. 75 per cent for the general inmate population. Lower Mainland Regional Correctional Centre was closed in 1991. The site is now a park.

Similar studies by different doctors carried out on inmates at Kingston Penitentiary in Kingston, Ont. in the 1960s, in Illinois starting in the 1930s and in Texas in the 1980s had similar results. The theory is still in use today by non-profit organizations in the U.S. which help reformed former gang members to remove facial and body tattoos to help get them out of gangs into jobs. I have been a I volunteer tattoo removal doctor in Los Angeles since the mid-1990s to help get people out of gangs. The patients pay for their treatments by performing volunteer community services and some have gone on to well paying executive or managerial positions. I don't think many people today would support free cosmetic surgery for inmates. In this crazy world some would commit crimes just so they could get the free surgery.

The best way to rehabilitate Two Face back to Harvey Dent would have been Plastic Surgery.

The BBC is currently looking for anyone involved to be in a documentary about the study.

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Body Dysmorphic Disorder - BDD and Plastic Surgery

July 4, 2015, 8:05 pm

≫ Next: Beauty is in the eye of the beholder - Where You Live

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Body dysmorphic disorder (BDD) is a syndrome characterized by a strong preoccupation with an imagined defect in a person’s appearance. In cases where the deficit is not imagined and a slight defect is present, the person’s concern is noticeably excessive. Excessive preoccupation with the imagined or minor flaw involves intrusive thoughts about the body part of concern. In addition to daily intrusive thinking, individuals suffering from BDD engage in a variety of compulsive behaviors aimed at alleviating the anxiety caused by the thoughts. Patients with BDD generally engage in thoughts and behaviors related to their perceived deficit for 1 hour or more per day, and that amount has been reported as high as 3 hours per day among adolescents. Symptoms often start in adolescence or early adulthood brought on by remarks made by peers or family members i.e. early bullying and family attachments are significant factors. The average age of onset is 16 to17 years, although it may occur in older adults overly concerned with their aging appearance. Individuals with BDD frequently check their appearance in mirrors to confirm or attempt to conceal the perceived deformity. They may engage in long rituals of grooming, such as repeatedly combing or cutting their hair to make it just so, applying make-up, or picking at their skin. They typically will spend a great amount of time trying to cover up or camouflage the perceived defect employing elaborate clothing rituals. They will seek excessive reassurance from friends, family members, and/or co-workers to elicit placation that the perceived “defect” does in fact exist, or to assure that the flaw is sufficiently concealed. At the extreme they feel anxious around others, avoid social situations, become housebound, only leaving their homes at night to avoid the scrutiny of others. Some drop out of school, avoid job interviews, or do not work in order to avoid public exposure . Patients with BDD have attempted to engage in self-surgery with knives or razor blades to pick at or remove the blemish or with staples to tighten “loose skin". Clearly they see something that others do not see real, imagined or exaggerated.

Since the rise of smart cellphones, social media and reality television promoting narcissistic behavior the majority of BDD patients have a compulsion to repeatedly take and post selfies on social media sites. They might take several selfies over and over again until they find the right one. Picking out details about their eyebrows, skin, noses, smiles, teeth, hair and so forth, all in an attempt to find the perfect angle to make the perfect picture. As harmless as these acts all seem, they build up over time to create great forms of self consciousness and false sense of confidence feeding on itself as an ever growing consuming obsession and compulsion. Instead of being okay with who they are no matter what, they strive to find the right picture with all the perfect details. The more likes they get on social media sites the happier they feel. Narcissism, being obsessed with receiving recognition and gratification from ones looks, vanity and in an egotistical manner, is becoming a big problem in our digital age. A recent survey showed that 16-25 year olds spend on average 16 minutes and seven attempts to take the perfect selfie.

Danny Bowman, a British teenager, became so obsessed with capturing the perfect shot that he would spend roughly 10 hours per day taking up to 200 selfies trying to get the perfect shot. As things got more and more intense for Danny, he lost nearly 30 pounds, dropped out of school and did not leave the house for six months as he kept trying for the perfect picture. He attempted to commit suicide because he was unable to take what he felt was the perfect selfie but the attempt was thwarted by his mother. He stated that he “was constantly in search of taking the perfect selfie and when I realized I couldn’t, I wanted to die. I lost my friends, my education, my health and almost my life.” 40% of BDD sufferers experience suicidal ideation at some point throughout the course of their illness.

Concerns with weight fall into a separate eating disorder classification. BDD can manifest as eating disorders, obsessions with exercise and fitness and addiction to plastic surgery though the Diagnostic Statistics Manual considers them separate entities for descriptive usefulness. Even the rich and famous can be affected. Former British glamor model, Alicia Douvall, who associated with music mogul Simon Cowel and was linked to actor Mickey Rourke and Simply Red singer Mick Hucknall spent over £1m on over 300 procedures. At one point she underwent one operation a week because she was convinced that she was ugly.

Alicia Douvall had 71 operations and 260 procedures

Yet in 2013 she turned on her plastic surgeons saying they never refused her even when she brought a Barbie doll with her to illustrate what she wanted to look like.

Looking at Michael Jackson over the years as he gained then lost his nasal bridge, his wide base narrowed then collapsed and his implant began to protrude through the tip it is obvious that he was the text book definition of BDD.

A man in his early twenties once came to see me in consultation for a rhinoplasty. His avoidance behaviors and exaggerated reactions to my physical findings were a red flag. I told him it was my policy to send males in his age group for this surgery for evaluation by a psychologist. Luckily, I had another patient who was a psychologist specializing in BDD. To my surprise a phone call corroborated the diagnosis of severe BDD with suicidal tendencies, and avoidance of socialization by not working and spending most of his time at home where he was cared for and medicated by his physician parents. I was warned not to operate on him no matter what. Another female patient was overly concerned about her facial bones and her urgency in obtaining surgery for non-existent deformities was alarming. I sent her to the same psychologist who told me that she did not have BDD which surprised me even more than the assessment of the man in his twenties. Needless to say I refused to perform surgery on both of these patients.

In light of the risks and harms cosmetic surgery can cause patients with BDD, having a systematic process for identifying such patients is imperative. A study published in January 2015 described a screening questionnaire using utilized the Body Dysmorphic Disorder questionnaire (BBDQ) and the Body Dysmorphic Disorder Structured Clinical Interview for DSM-IV (BBD SCID) in 234 patients presenting for facial plastic surgery for this purpose. They confirmed a diagnosis of BDD in 13.1% patients undergoing cosmetic surgery and in 1.8% of those undergoing reconstruction surgery. The BDDQ was determined to be 91.7% accurate, 100% sensitive and 90.3% accurate in screening patients for BDD, according to the researchers. In patients with BDD, the nose was determined to be of most concern (56%), followed by the skin (28%), hair (6%), chin (6%) and ears (6%). Those with markedly excessive concern over their noses report distress regarding its size or shape. Concerns with the skin typically involve acne, wrinkles, and spots. Thinning and balding are usually the main concerns reported among individuals preoccupied by their hair. Patients with BDD were found to have elevated depression levels compared with patients without BDD. This explains why Michael Jackson had more nose surgery than any other surgery.

Other epidemiologic studies have shown

52% are women, 75% are Caucasian, 12% are Afro-American and 12% are Hispanic.

Three out of 4 people with BDD are unmarried; however, women with the disorder are more likely to be married and men more likely to be single.Women are frequently troubled with their overall weight and the size of their hips, waist and breasts; men are more distressed about their height, genitals, penis size and hair. Men are also more likely to exhibit a specific type of BDD, referred to as muscle dysmorphia, a preoccupation with being too skinny and lacking enough muscle that leads to anabolic steroid use. Over the last decade buttock size has been a major focus for a variety of reasons. Leading to multiple deaths and deformities (see my blog Brazilian Butt Lift).

Areas of focus in men and women with BDD

Most patients are concerned with more than one body part at a time especially those obsessed with exercise, fitness and muscle size. In fact, the average BDD sufferer is concerned with three to four features at once.The overall prevalence of BDD in the U.S. population is 2.4%, but the incidence is significantly higher within the cosmetic surgery population. Among cosmetic surgery patients, the reported prevalence rates range from 2% to 7%, and the rates range from 9% to 15% among dermatology patients. Thus the prevalence of BDD among the overall aesthetic patient population may be up to 7 times higher than in the general population.

Although BDD is treatable most people with BDD delay seeking help for fear of being dismissed as vain. The earlier it is diagnosed, before the thoughts and anxieties have become fully ingrained, the easier it is to treat. Treatment consists of a combination of an anti-depressant medication and cognitive behavioral therapy with a psychologist/psychiatrist before and after, or instead of a cosmetic procedure.Cognitive therapy teaches patients to identify unhelpful thought patterns and replace them with more constructive ones, control anxiety and obsessional rituals, increase self esteem and feel more comfortable in social situations. It does not focus on the cause of BDD. It can take several months for the treatment to take effect. The minimum treatment duration is 2 to 3 years and medication may need to be taken for life to prevent relapse. Psychoanalysis is time consuming, expensive and an unproven treatment for BDD. The BDD sufferer on the other hand is convinced surgical or medical treatment is necessary and psychological treatment will not resolve their problems. While delaying appropriate treatment the BDD sufferer may try to cure themselves with plastic surgery but only 10% of those who do will be happy with the result of their surgery. Hence the propensity for them to have multiple procedures. Sadly in today's world if you look hard enough, you will find someone who will do almost whatever surgery you want. A large number of those who undergo plastic surgery experience a worsening of their BDD symptoms, while others may develop a preoccupation with another body part. Studies have consistently demonstrated that the majority of people with BDD do not benefit from cosmetic treatment.

Family members of someone with BDD should:

avoid debating the existence of the perceived defect because that can entrench the delusion
set boundaries such as being alone in bathroom time
avoid contributing or condoning rituals or avoidance behaviors such as making excuses to employers or providing camouflage materials
not supply money for cosmetic surgery because the surgery will not solve the problem
encourage treatment by a psychologist or psychiatrist specializing in BDD because it is highly unlikely they will initiate appropriate treatment on their own

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Beauty is in the eye of the beholder - Where You Live

October 1, 2015, 3:59 pm

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With modern globalization the most popular films and products are pretty much the same all over the world. Individuals now travel far from home for plastic surgery. That is called medical tourism. At first glance it seems we have reached a global agreement on what beauty consists of. On closer examination we find that is not true.

A survey of 214 Plastic Surgeons from 69 different countries, published in June 2015, revealed that these surgeons had significantly different preferences for upper breast fullness, areola size in the natural breast, and areola size in the augmented breast based on the country they lived in and their age and independent of their ethnic background. The survey was performed by showing the surgeons computer images that they could make direct adjustments to. Surgeons from India preferred the most full look, while surgeons from France preferred the least upper-breast fullness. Brazilian surgeons preferred the largest areola size, both in natural breasts and in breasts with implants, while German surgeons preferred the smallest areola size. Older surgeons preferred less upper breast fullness and larger areola size.

It turns out it's not just the surgeons. In another study onlinedoctor.superdrug.com commissioned Fractl to investigate perceptions of beauty around the world. Fractl contacted 18 designers (14 women and 4 men) in 18 different countries on 5 different continents and gave them a photo of a woman to Photoshop and retouch to modify haircolor, clothes, shape and form to make her more attractive to citizens of their respective countries.

Full-sized Photoshopped images:

Not only were the body shapes and facial features changed, but the clothing (underwear, boots, etc.), hair and skin color were also altered. While countries like Columbia and Spain returned an image similar to the original, others — including the U.S., Argentina and the Philippines — show an exaggerated form of the classic hourglass figure and still others — Italy and China — are the thinnest “preferred” body types. The Netherlands seems to prefer boots and red hair. Egypt, Venezuela and Mexico prefer darker hair. What is concerning is that China and Italy prefer an anorectic or starved body shape.

A follow up study is pending for a photo of a man.

Unfortunately the Plastic Surgeon survey did not overlap sufficiently with designer survey in terms of country lived in. The take home message however is in an increasingly global environment, cultural differences and international variability must be considered when defining plastic surgery goals and outcomes. When both the plastic surgeon and the patient are able to adequately and effectively communicate their preferences to each other, they will be more successful at achieving satisfying results and patients will more likely choose the right surgeon for their needs.

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Labiaplasty

October 20, 2015, 6:53 pm

≫ Next: Tummy Tuck - Abdominoplasty Complications

≪ Previous: Beauty is in the eye of the beholder - Where You Live

Vaginal labiaplasty refers to surgical reduction of the labia minora. Additional goals of this procedure include minimal invasiveness, preservation of the introitus, optimal color/texture match, and maintenance of the neurovascular supply.[1] Labiaplasty has become an increasingly popular in recent years.[1] There are no widely accepted guidelines for labiaplasty, and it is carried out for a variety of reasons. Hypertrophy of the labia minora can cause dyspareunia, chronic urinary tract infections, irritation, hygienic difficulties, and interference with sports.[2,3] What constitutes labial hypertrophy is poorly defined in the literature. Historically, authors have assigned varying distances from the midline to the lateral free edge of the labia minora as abnormal. Others have advocated for surgery only in the presence of chronic symptoms.[1] More recently, a system taking into account labial protrusion as well as the distance from the lateral edge of the labia minora to that of the labia majora has been proposed.[1] Although there is no established anatomic standard, reports suggest that woman prefer a prepubescent aesthetic, with the labia minora tucked within the confines of the labia majora.[1] A study evaluating 131 patients undergoing labiaplasty found that 32% sought surgery for functional impairment or discomfort, 37% sought surgery for aesthetic purposes, and 31% sought surgery for a combination of these reasons.[3] Because of poorly defined anatomic parameters and a lack of widely accepted indications, labiaplasty is somewhat controversial despite a high rate of patient satisfaction following the procedure.[4] Several labiaplasty techniques have been described including deepithelialization, direct excision, wedge resection, and composite reduction. Deepithelialization removes a small amount of tissue while preserving the labial contour. It is best suited for patients with minimal hypertrophy.[1] Direct excision is a straightforward approach to volume reduction; however, the aesthetic outcome is poor. The natural color, contour, and texture are lost. Furthermore, the scar may be visible.[5] Wedge resection accomplishes a comparable volume reduction with direct excision while preserving the native labial contour.[1] Composite reduction labiaplasty aims to correct clitoral protrusion and hooding in addition to labial reduction. Composite reduction is associated with a higher rate of complications and reoperation than other techniques.[6] Additional procedures such as W-shaped resection, Z-plasty, and laser labiaplasty have been described in a small number of patients.[1] Choice of technique should be based on patient anatomy, goals, and surgeon comfort. The most common complications following labiaplasty are dehiscence, hematoma, unsatisfactory scarring, and superficial infections. In addition, flap necrosis has been reported with wedge resection.[1] Labiaplasty is an increasingly popular procedure with high satisfactions rates, although the definition of labial hypertrophy and indications for surgery remain debated. Several techniques are available to accomplish labial reduction, and future studies are needed to establish practices optimizing patient care

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Tummy Tuck - Abdominoplasty Complications

November 9, 2015, 7:15 pm

≫ Next: Malar Bags

≪ Previous: Labiaplasty

Healthcare including cosmetic surgery today is increasingly data driven. The computer and internet age has allowed the pooling of information or data from multiple sources. These include insurance billings, hospital admissions, medicare billings, medical specialty society online trackers such as the American Society of Plastic Surgeons TOPS, etc. This data is periodically pooled and analyzed for trends over time, incidence of complications, hospital re-admissions, surgeon report cards, malpractice claims won or lost and so on.

Analysis of claims against insurance that covers for major complications of cosmetic surgery from 2008 to 2013 showed that major complications occurred in 4 percent of tummy tucks, compared with 1.4 percent of other types of cosmetic surgery. The most common major complications that were covered were hematomas (collection of blood outside blood vessels that usually present as tense bulges in the skin and deeper tissues such as a wrestler's cauliflower ear), infections, blood clots and lung-related problems. This type of insurance does not cover minor complications and is separate from health insurance, which typically does not cover complications due to non-covered cosmetic surgery. The risk of major complications was 50 percent higher when patients had other cosmetic procedures at the same time as a tummy tuck. Male, obese and patients aged 55 or older were also at increased risk. The risk was lower if a tummy tuck was performed in an office-based surgical suite rather than in a hospital or surgical center, although that may be due to sicker less healthy patients being more likely to have this surgery in a hospital setting.

Tummy tuck is the sixth most common cosmetic procedure performed in the United States. More than 117,000 were performed in the US in 2014.

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The Difference Between Abdominoplasty and Panniculectomy
Abdominoplasty Muscle Tightening

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Malar Bags

March 18, 2013, 2:40 pm

≫ Next: Improving Calf Definition by Calf Implant Surgery or Fat Grafting

≪ Previous: Tummy Tuck - Abdominoplasty Complications

There are 3 separate entities lower eyelid bags, festoons and malar bags.

Lower eyelid bags refers to protruding fat or redundant muscle in the lower eyelid itself above the level of the bone rim under the eye.

Tear trough exaggerated by protruding eyelid fat

Lower Eyelid Bags
Festoons refers to redundant folds of skin with or without muscle in the lower eyelid.

Festoons

Malar pouches, bags or saddlebags are a prominence below the level of the bone rim under the eye due some combination of swelling or edema, drooping eyelid muscle (orbicualris oculi muscle) and fat under the muscle herniating through the muscle. The lower edge of the malar bags is defined or limited by the zygomatico-cutaneous ligament which has also been called the malar septum. This ligament stops the discoloration of a black eye from spreading down into the cheeks. There is a lot of misinformation on the web regarding malar bags, even on online question boards answered by surgeons. Some people call the bags malar crescent.

The presence of malar bags can be related to previous eyelid or nose surgery independent of who your surgeon was, a complication of dermal filler injections that block normal lymphatic flow, the aging process, genetics, allergies, sinus infections, lack of sleep, water retention (related to menses, kidney insufficiency etc.), liver cirrhosis or thyroid conditions (hypo or hyperthyroidism). The chances of them appearing after dermal filler injection is reduced if smaller beads of filler are placed closer to the underlying bone and aggressive massage of the area is avoided. I get them temporarily when my allergies act up and I lose sleep.

The acute onset of malar bags such as those seen after eyelid surgery is best treated with anti-inflammatory steroids with or without diuretics and sleeping with 2 pillows under your head. Those related to allergies should first be treated with antihistamines and avoidance of inciting allergens. The injection of 20 units of Vitrase (hyaluronidase) will quickly resolve malar bags caused by injection of a hyaluronate like Restylane or Juvederm. Chronic malar bags require a medical workup to assess for one of the causes listed. That involves blood tests such as complete blood count with differential, erythrocyte sedimentation rate, serum protein electrophoresis, cryoglobulin and cryofibrinogen testing, rheumatoid factor, antinuclear antibodies, thyroid levels and liver or kidney function blood tests. A history and physical examination will inform your doctor which if any of these tests would be required..

For chronic malar bags where a medical condition is not present or has been controlled through medications surgery can be helpful. Superficial liposuction (with the cannula holes facing away from the skin) of these malar bags via a small incision near the outer corner of the eye was first described in 1984. More recently this same liposuction via an incision at the nostril rim-cheek crease and suture elevation of the muscle to the temple muscles was described.

This is a patient in whom I sutured the eyelid protruding fat to the deep cheek fat and liposcutioned fat in the malar bag between the skin and the eyelid muscle. No skin was removed. A similar though usually temporary result can be achieved using dermal filler injections.

This is a patient who underwent malar bag liposuction and muscle suture elevation elsewhere.

Nasojugal Crease - Tear Trough Deformity
Blepharoplasty
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Improving Calf Definition by Calf Implant Surgery or Fat Grafting

March 1, 2016, 8:21 pm

≫ Next: 11 Reasons for Not Having Plastic Surgery

≪ Previous: Malar Bags

In a woman the maximal circumference of an aesthetically pleasing leg should be less than one-fifth of her body height and the ideal aesthetic contour of the leg has been defined as relatively flat in the medial upper third of the calf, with a gradual tapering to the ankle. Calf asymmetry is defined as a difference in the maximal circumference greater than 2.0 cm between both calves when standing on tip toes. Asymmetry can be due to surgery, sports activities, nerve injury or obesity. Bodybuilders want larger more well defined calf muscles and most women want slender longer looking legs, especially if they are shorter in height.

The shape of the calf is determined by the development of gastrocnemius and soleus muscles, the length and orientation of the lower leg bones, and the subcutaneous fat distribution. Cosmetic surgery of the lower legs between the knees and ankles may be desired for a variety of reasons such as lipedema or stove pipe legs, hypertrophied or large calf muscles, small calf muscles, right left calf asymmetry, insufficient calf definition etc.

The surgical approaches that have been employed include calf implant insertion, fat injection, selective nerve removal or neurectomy, liposuction, muscle resection, radiofrequency shrinkage of soft tissue and botulinum toxin injection into the muscle. In some cases a combination of procedures are employed such as implants and fat grafting for patients who get calf implants and have thin ankles.

The first implants used for calf augmentation in the 1980s were silicone gel filled and similar to breast implants. Harder implants began to be used in the 1990s. Now we have solid and semisoft silicone including cohesive material which more closely resembles calf muscle and can be bought off the shelf or custom made using a moulage. In order to get proper definition and calf muscle or muscular outline 2 calf implants are usually needed per leg using a larger implant over the outer gastrocnemius muscle. They are inserted via an incision in back of the knee and the implants are placed between the gastrocnemius muscles and their fascial coverings. It is important to keep an intact septum between the implants so that they do not run into or overlap each other. Due to compression by the implants and swelling the patient may have difficulty walking for a week and should limit ambulation during that time. All patients must avoid strenuous activities and wear compression garments for 3 months after calf implant surgery. The disadvantages of calf implants are possible future capsular contracture, seroma (pockets of fluid), infection, implant extrusion through the skin and erosion of the surface of any bone they sit on. If you develop circulation problems or diabetes with aging the implants will have to be removed.

It is crucial that an appropriate sized implant is inserted and activity restrictions are followed strictly after surgery because excessive swelling, too large an implant or infection can result in compartment syndrome and permanent muscle damage or worse. The bodybuilder girlfriend of one of my patients had her calf implants placed in Mexico. They subsequently became infected and she ended up requiring amputation below the knee on one side.

Fat injection or grafting to the calves involves liposuction on an area of the body containing unwanted fat. Then the fat is grafted onto the calves to make them larger. The main drawback of fat injection is that 2 to 4 sessions may be required with 2 to 3 month intervals between grafting sessions. Fat injection offers many advantages, including the use of autografts; small, less visible scars; no late complications; the opportunity to perform touch up injection; the ability to increase size with future procedures; lack of foreign body rejection; more precise size adjustment than implants alone; satisfactory long-lasting results; and no need to reverse the procedure if you develop diabetes or circulation problems when older. The best candidates for liposuction have pinch thickness of skin and fat greater than 1.5 cm at the central calf and 1.0 cm at the ankle. Liposuction patients also require compression garments for 2 to 3 months after surgery.

Neurectomy although a well reported procedure is best reserved for extreme cases because it permanently and irreversibly damages leg muscles.

The main problem with any surgical approach is a visible scar that no patient wants to see or be seen. Therefore most surgical incisions in the area are confined to the skin crease in back of the knee or behind either ankle bone. Although they fade over time they have a tendency to widen and be darker than the surrounding skin.

Lipedema, Lymphedema and Fat Legs
Free Fat Grafting
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11 Reasons for Not Having Plastic Surgery

March 13, 2016, 11:40 pm

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The primary reason a person may decide against having plastic or cosmetic surgery is not always the price of the procedure and in fact price may have nothing to do with their decision.

Cost

available financing options

Lack of connection with the surgeon.

Didn’t connect with the patient care coordinator.
No family support.
Fear of scars.
Surgeon's plans do not match patient's expectations or desires.

Fear of anesthesia.
Worried about the result.
Afraid of being judged.
Fear of making a decision.
Scheduling or timing issues.

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Dark Circles Under the Eyes

March 23, 2016, 1:11 pm

≫ Next: Labiaplasty and Vaginoplasty

≪ Previous: 11 Reasons for Not Having Plastic Surgery

Patients with dark circles under their eyes complain that they look tired. The condition is called periorbital hyperpigmentation. Environmental factors that make the condition worse include sunlight exposure, hayfever, lack of sleep, stress, alcohol overuse and smoking.
The condition is classified by appearance as:

pigmented (brown color)-congenitally darker skin, nevus of Oti or Hori, dermal melanocytosis, side effect of eyedrops, inflammatory induced pigment increase associated with atopic or allergic dermatitis or eyelid rubbing associated with allergies
increased pigmentation from inflammation
vascular (blue, pink, purple color)-increased blood vessel density
blue color and structural (tear trough) both treated by filler injection
thin skin making the underlying muscle color visible
thin lower eyelid skin shows muscle under it
structural (shadows formed by the surface contours such as eyelid bags, eyelid swelling or tear trough visibility associated with aging)
shadows from eyelid bags
mixture of 2 to 4 of the above classes

structural shadow from malar bags and over pigmented brown lower eyelid skin that is more visible after bags are removed

The treatments available fall under 2 categories:
Topical depigmenting agents

hydroquinone
kojic acid
azelaic acid
arbutin
retinoic acid

Other modalities

chemical peels-glycolic acid 20% or lactic acid 15%+trichloroacetic acid 3.75%
filler injections
surgery-fat grafting, blepharoplasty
laser-Q switched ruby (694nm), Q switched alexanderite and Nd:Yag (1064nm)
stop medications causing the condition

Hydroquinone in 2 to 6% strength applied to the eyelids is effective and safe but cannot be used long term because of the risk of ochronosis, a permanent skin discoloration. Kojic acid comes from the same mold as penicillin. It can be applied in 1 to 4% concentration to lighten skin color but can irritate the skin. Azeliac acid works by killing pigment cells, is well tolerated by the skin and can be used long term without side effects. Arbutin is a plant extract that inhibits pigment manufacture and maturation of the cell packet containing pigment but at concentrations can have the opposite effect.
Combination formulas such as Klingman's (4% hydroquinone, 0.05% retina-A, 0/01% steroid) and a mix of Kojic acid, 10% glycolic acid and 2% hydroquinione are FDA approved for skin lightening but again have risks associated with long term use. In darker skinned individuals chemical peels may create a visible line of demarcation between peeled and non-peeled skin or may be contraindicated. For optimal results peeled skin should be pretreated with retin-A and hydroquinone for 2 to 4 weeks. Lasers such as have yielded good results especially when the skin is pretreated. Structural causes of dark under eye circles can be treated with blepharoplasty, fat grafting and/or filler injections.

Latanoprost and bimatroprost eye drops, used to treat glaucoma, stimulate increased eyelid skin pigment production by pigment cells. The pigmentation becomes visible after 3 to 6 months of use and reverses when eye drops are discontinued. If the dark circles disappear in direct lighting or when the eyelid skin is stretched the problem is structural and the surface contour is creating a shadow. If the dark circle gets darker the problem is thin skin and as you thin it even more by stretching it the underlying muscle shows through even more.

Eyelid Surgery-Blepharoplasty/
Skin Bleaching
Nasojugal Crease - Tear Trough
Dr. Aaron Stone - Plastic Surgeon Los Angeles
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Labiaplasty and Vaginoplasty

April 28, 2016, 4:54 pm

≫ Next: Eyelid Bumps

≪ Previous: Dark Circles Under the Eyes

Vaginal labiaplasty or simply labiaplasty refers to surgical reduction of the size of the labia minora or creation of labia in transgender surgery. This blog only covers the reduction surgery. The procedure has become an increasingly popular in recent years and is carried out for a variety of reasons. In its 2014 national totals for cosmetic procedures, ASAPS reported surgeons performed 7,535 labiaplasty procedures in 2014. Labiaplasty increased by 49% compared to the prior year, and nearly 90% of those patients were 19 to 50 years old. In 2015 the number of procedures increased another 16% to 8,745. However, the number of labiaplasties performed on girls 18 under was 80% greater in 2015 than 2014, which is alarming. Since these number only include Plastic Surgeons the actual US numbers are likely much higher when procedures performed by Gynecologists are included. During this same period of time breast augmentation for teenagers and adults together only went up 6.7%

Increasing trends in pubic hair removal, genital piercings that stretch the tissues, exposure to idealized images of genital anatomy, and increasing awareness of cosmetic vaginal surgery have been proposed as reasons for the increased interest in labial surgery. Gynecologists who care for teenage girls say they receive requests every week from patients who want surgery to trim their labia minora. The alarming increasing among teenagers prompted the American College of Obstetrics and Gynecology to release guidelines for adolescents requesting the surgery. The first step is education and reassurance regarding normal variation in anatomy, growth, development and the temporary changes associated with puberty. The second step is nonsurgical comfort and cosmetic measures including supportive garments, personal hygiene measures (such as use of emollients), arrangement of the labia minora during exercise, and use of formfitting clothing may suffice. If emotional discomfort or symptoms persist, then surgical correction can be considered but only after counseling and assessment of the adolescent’s physical maturity and emotional readiness and screening for body dysmorphic disorder. All adults should also be screened for body dysmorphic disorder if there is no obvious medical condition related to enlarged labia. The surgery should not be performed when the patient is menstruating to reduce potential hormonal effects and the increased risk of infection. The use of similar guidelines in Australian public clinics resulted in a 28% decrease in the number of labiaplasties performed in 2015 vs. 2014. Though 2012 through 2014 rates of the surgery in Australia were basically unchanged. Women in Australia who apply to have publicly funded labiaplasty must now provide an expert review panel with photographs of their genitalia, so they can be assessed for unusual physical symptoms that need repair, or they are told that they fall within the range of normal variation and surgery is not required.

Enlarged labia minora can cause dyspareunia (pain with sexual intercourse), chronic urinary tract infections, local irritation with skin/musoca breakdown, hygienic difficulties especially after menses, urination or bowel movements, and interference with sports such as cycling, walking or running. However, there is no accepted exact definition of enlarged labia minora. Labial minora protrusion relative to labia majora is classified as Class I (0-2 cm), Class II (2-4cm), and Class III (>4 cm). A study evaluating 131 patients undergoing labiaplasty found that 32% sought surgery for functional impairment or discomfort, 37% sought surgery for aesthetic purposes, and 31% sought surgery for a combination of these reasons. Often, the issue is that there is an asymmetry and one side is larger than the other so, sometimes, the surgery is only performed on one side. Reports suggest that women prefer a prepubescent aesthetic, with the labia minora tucked within the confines of the labia majora (Class I). Because of poorly defined anatomic parameters and a lack of widely accepted indications, labiaplasty is somewhat controversial despite a high rate of patient satisfaction following the procedure.

While labiaplasty can be done with just local anesthetic, patients are more comfortable with a combination of local anesthetic and sedation. The local should be lidocaine with epinephrine, 1:100,000 injection, to reduce bleeding during surgery and after surgery bruising and swelling.

Several surgical approaches to labiaplasty have been described

deepithelialization:
direct excision or edge resection:

edge resection

wedge resection:

wedge resection with step

composite reduction:
miscellaneous:

The technique chosen depends on patient anatomy, goals, and surgeon comfort while preserving the vaginal opening, color/texture match, and the nerve/blood supply. The most common complications following labiaplasty are separation of the suture lines, hematoma/bleeding, unsatisfactory scarring, and superficial infections. Excessive or insufficient tissue removal and asymmetry after surgery can also be problems. In addition, flap necrosis has been reported with wedge resection. Despite that the procedure is increasingly popular with high satisfaction rates. Suture line separation is minimized by tension free closure, use of longer lasting absorbable sutures (removing non-absorable sutures is painful and uncomfortable for the patient and the surgeon) and restraining from sex or exercise until the area is healed. One of my patients went dancing within a week of surgery, tore the repair on one side and had a less than optimal result on that side.

Care after surgery involves topical antibiotic ointment covered with gauze or sanitary pad for the first 24 hours. The area is cleansed with water sprayed from a water bottle like device after urinating and patting dry with gauze to prevent urine from getting on the suture line for the first 3 to 5 days after surgery. Exercise, vigorous physical activity including dancing, tampons and sexual activity should be avoided for 3 to 4 weeks after surgery.

Vaginoplasty refers to surgery inside above the vaginal opening or creation of a vagina in transgender surgery. It can be performed to correct a congenital deformity, narrow the vaginal diameter, reconstruct the vagina after surgery, treat prolapse or treat urinary incontinence. Tightening the vaginal tissue in itself cannot guarantee a heightened sexual response, since desire, arousal, and orgasm are complex, highly personal responses, conditioned as much by emotional, spiritual, and interpersonal factors as aesthetic ones.

Historically this was performed by excising a diamond shaped segment of tissue from the back wall.

Currently laser resurfacing, laser excision and radiofrequency modalities are more frequently employed.

Thermiva handpiece that is inserted for radiofrequency vaginoplasty. The radiofrequency heats up and shrinks the tissue. After 3 to 5 treatments patients report a high degree of satisfaction, resolution of urinary incontinence... The treatment is relatively new but it appears that short maintenance treatments are then required once a year.

Body Dysmorphic Disorder - BDD and Plastic Surgery

Female Genital Cosmetic Surgery
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Eyelid Bumps

June 13, 2016, 12:21 pm

≫ Next: Opioid Prescriptions and Pain Following Surgery.

≪ Previous: Labiaplasty and Vaginoplasty

Syringomas are benign tumors of eccrine sweat ducts in the skin, first described in 1872. They appear as solitary or multiple small (1 to 3 mm diameter), soft to firm, skin-colored to slightly yellowish symmetrically distributed papules or bumps. The distribution may be localized or generalized. Localized syringomas are the most common and are usually found on the eyelids. Generalized syringomas are found mainly on the chest and neck, followed by the forearms. However, syringomas may appear on other body areas such as the penis, armpits, and buttocks. They are presumed to be due to chronic inflammation of the sweat glands or plugging of their ducts by the overgrowth of skin.

Syringoma localized to the lower eyelid.

Generalized syringoma of the neck and chest.

They usually appear at puberty or in the third and fourth decades of life and are more common in Asians, African Americans and females. Family inherited cases have been described. Since they are not associated with any symptoms or cancers they are mainly a cosmetic problem. A number of treatment modalities are available, including surgical excision by scalpel or punch, Erbium or CO2 laser surgery, electrodesiccation, dermabrasion, chemical peeling, cryotherapy, topical tretinoin (retin-A), and combinations of these methods but complete removal is uncommon and no single treatment method has been shown to consistently work. Since they extend below the skin surface a superficial treatment alone will not suffice and because they tend to be multiple it is safer to treat them in a piecemeal fashion. Punch excision of larger lesions and a trial of low-voltage electrodessication and trichloroacetic acid chemical peel are suggested before treating all lesions. Syringomas are particularly difficult to treat in darker skinned individuals because of the added risk of skin discoloration or bad scarring.

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Opioid Prescriptions and Pain Following Surgery.

July 12, 2016, 2:48 pm

≫ Next: Non-Surgical Rhinoplasty

≪ Previous: Eyelid Bumps

Over the last few years the state and federal governments have been making it harder for doctors to prescribe opioid pain medications outside of the hospital, even after surgery. After my initial panic response I found alternatives in the medical literature. Since then I have been prescribing a Tylenol Motrin mix that has worked well in my mostly healthy patient population after surgery. In fact some patients have told me they prefer this approach to the standard opioid prescriptions because of the nausea, constipation, loss of concentration etc. associated with opioids. Now researchers from Stanford University School of Medicine published a review of the records of more than 641,000 patients who underwent one of 11 common operations and were not taking opioid pain medication during the year prior to surgery. They found that some patients were 1.5 to 5 times more likely at risk for chronic opioid use/abuse following surgery depending on the procedure. Males, the elderly, patients with a history of drug or alcohol abuse and those taking Valium like medications prior to surgery were at higher risk though the overall risk was low at about 1%. Now if the hospitals and surgery centers carried Exparel life would be much easier.

Controlling Pain After Cosmetic Surgery
Dr. Aaron Stone - Plastic Surgeon Los Angeles
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Non-Surgical Rhinoplasty

August 10, 2016, 4:19 pm

≫ Next: Plastic Surgery Around the World in 2015

≪ Previous: Opioid Prescriptions and Pain Following Surgery.

Asian Patient Before-After Surgical Rhinoplasty with Medpor Implant to the Bridge

Non-surgical rhinoplasty has been around since the early 1900’s when surgeons used liquid paraffin to correct nasal imbalances. Although the corrections proved effective, the paraffin wound up being harmful to the body. As were the silicone fillers of the 1960’s. It’s only recently with the advent of hyaluronic acid fillers such as Voluma, Belotero, Juvederm and Restylane that the non-surgical rhinoplasty has become a plausible reality.

This month an article published in Dermatologic Surgery and another in Aesthetic Surgery Journal tout the benefits of non-surgical rhinoplasty with injection of a hyaluronate filler into the nose. The first out of a South Korean clinic used the filler to augment the bridge and/or rotate the tip with a 1% rate of vascular complications. Those cases were attributed to the use of a needle instead of a cannula but they did prove the efficacy of the procedure. The second looked at Asian patients in Australia and Brazil undergoing the procedure and reported that nearly 80% were satisfied or very satisfied with the filler treatment 12 months out. 85 to 90% said they would recommend the procedures to others. It is not clear which hyaluronate is best for this procedure or if other types of fillers can/should be used.

The take home message is non-surgical filler rhinoplasty can produce temporary results that are comparable to surgical augmentation rhinoplasty. However, the key word is temporary and this is likely best used on the bridge below the radix level or injected from below upwards. Injections directly into the radix near the eyebrow level, in the tip or on the sides/creases of the nose where the blood vessels are is more likely to result in vascular complications i.e. skin and possibly deeper tissue loss. The material can cause a problem by being injected directly into an artery or vein or by compressing a blood vessel by mass effect. Some fillers absorb water over time like a sponge so their compressive effect is delayed. There is a remote chance the injected material migrates to the eye causing blindness. If you have increasing intolerable pain after these injections you may have impending skin loss and need to be treated within 24 hours. The best way to avoid a complication is to not inject directly into the areas described above, make a skin hole with a small 22G needle near the midline and then inject through this hole with a 25G blunt tipped cannula. Some doctors mix the hyaluronate with local anesthetic to thin it and make it less likely to adversely affect blood vessels.

The best candidates for this procedure are those with deficient nasal bridges and thick nasal skin (like Asians), those who cannot undergo the down time associated with surgery, those who are prone to or afraid of complications like scar contracture or thinning of the nasal tip and those who cannot afford surgery or want to try out the surgical result before committing to surgery. You of course cannot refine the nasal tip, fix valve collapse, narrow a boxy tip, decrease tip projection, change columellar show or narrow the alar base by just injecting filler. Non-surgical filler rhinoplasty has a role but it cannot replace rhinoplasty surgery.

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Plastic Surgery Around the World in 2015

August 25, 2016, 12:37 pm

≫ Next: Skin Aging and Wrinkling by City and State

≪ Previous: Non-Surgical Rhinoplasty

The International Society of Aesthetic Plastic Surgeons released its worldwide statistics for 2015 which are interesting for the following reasons.

In 2015 the USA, Brazil, Mexico and South Korea accounted for 9.6% of the world’s population.

total world breast implants silicone 2015

Yet the USA accounted for 75% of the world’s total breast implant placement and 56% of its saline breast implant placements.

While brazil accounted for 26% of the world’s buttock implant placements.

And 21% of its buttock fat grafts.

The US and Brazil accounted for 7% of the world’s population but 30% of its liposuction procedures and 17 to 18% each of the world’s tummy tucks.

South Korea with less than 1% of the world’s population accounted for 10% of its rhinoplasties

and 8% of its eyelid surgeries.

The us and brazil were tops in surgical procedures but significantly more botox, fillers and other non-surgical cosmetic treatments were performed in the US. In summary for 2015 the south Koreans did proportionately more eyelid and nose surgery, the US breast and body procedures and Brazil did proportionately more buttock implants or fat grafts and body procedures. This is a reflection of what is considered better looking in each country relative to a baseline of their untreated population.

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Skin Aging and Wrinkling by City and State

August 30, 2016, 11:23 pm

≫ Next: 4 Types of People Who Should Not Have Plastic Surgery

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Skincare, maker of topical anti-aging skin care products, partners with

, an analyzer of American city demographics, to produce a yearly ranking of US cities with respect to skin aging and wrinkling. In their analyses the top 5 factors contributing to skin aging/wrinkling are low winter temperatures, extreme weather temperatures, commuter times, sunny days (UV exposure), and elevation. Other contributors are stressful living, dry heat, ozone pollution, sleep deprivation and smoking rates. Although UVB is blocked by glass up to 72% of the UVA radiation of the sun, that which damages and ages the skin, still penetrates ordinary glass. So those with long commutes have significant sun exposure. The risks for skin wrinkles obviously overlaps with skin cancer risks. In 2015 New York was the most wrinkle prone and Alaska was the least most wrinkle prone state. California came in at 36th , Texas at 38th and Florida at 32nd.

Their 2014 Wrinkle Risk rankings by city from worst to best (smaller number is more wrinkle prone) of the 50 Largest U.S. Metro Areas were:
1. Riverside-San Bernardino-Ontario, California
2. New York, New York
3. Philadelphia, Pennsylvania
4. Atlanta-Sandy Springs-Marietta, Georgia
5. Baltimore-Towson, Maryland
6. Denver-Aurora, Colorado
7. Chicago-Naperville-Arlington Heights, Illinois
8. Newark, New Jersey-Pennsylvania
9. St. Louis, Missouri-Illinois
10. Orlando-Kissimmee, Florida
11. Washington-Arlington-Alexandria, District of Columbia-Virginia-Maryland-West Virginia
12. Nashville-Davidson-Murfreesboro-Franklin, Tennessee
13. Tampa-St. Petersburg-Clearwater, Florida
14. Miami-Miami Beach-Kendall, Florida
15. Houston-Sugar Land-Baytown, Texas
16. Los Angeles-Long Beach-Glendale, California
17. Charlotte-Gastonia-Concord, North Carolina-South Carolina
18. Dallas-Plano-Irving, Texas
19. Phoenix-Mesa-Scottsdale, Arizona
20. Warren, Michigan
21. Edison, New Jersey
22. Indianapolis-Carmel, Indiana
23. Fort Worth-Arlington, Texas
24. Boston-Quincy, Massachusetts
25. Oakland-Hayward-Berkeley, California
26. Las Vegas-Paradise, Nevada
27. Nassau County-Suffolk County, New York
28. Detroit-Dearborn-Livonia, Michigan
29. Pittsburgh, Pennsylvania
30. Cincinnati-Middletown, Ohio-Kentucky-Indiana
31. Fort Lauderdale-Pompano Beach-Deerfield Beach, Florida
32. Providence-New Bedford-Fall River, Rhode Island-Massachusetts
33. Cambridge-Newton-Framingham, Massachusetts
34. Jacksonville, Florida
35. Austin-Round Rock, Texas
36. Sacramento-Arden-Arcade-Roseville, California
37. Seattle-Bellevue-Everett, Washington
38. Kansas City, Missouri-Kansas
39. Columbus, Ohio
40. Milwaukee-Waukesha-West Allis, Wisconsin
41. San Antonio, Texas
42. Virginia Beach-Norfolk-Newport News, Virginia-North Carolina
43. San Francisco-Redwood City-South San Francisco, California
44. Cleveland-Elyria-Mentor, Ohio
45. Portland-Vancouver-Beaverton, Oregon-Washington
46. West Palm Beach-Boca Raton-Delray Beach, Florida
47. San Jose-Sunnyvale-Santa Clara, California
48. Santa Ana, California
49. Minneapolis-St. Paul-Bloomington, Minnesota-Wisconsin
50. San Diego-Carlsbad-San Marcos, California

Riverside and San Diego are only two hours apart, but on opposite ends of the Wrinkle Ranking scale. Because Riverside has an above average number of hot, dry, sunny days with a lengthy commute (14% higher than average), while San Diego has a mild Pacific climate. New York residents have the longest commute (35% higher than average), are exposed to the top third of ozone and particulate pollution and have the third-highest number of sleepless nights. Denver earned the sixth position for scoring highest in the Environment category. Mile-High City’s residents have one of the highest skin cancer rates due in part to the thin air which is less able to absorb skin-damaging UV rays. It also has the second-lowest humidty and the 6th-highest level of ozone pollution. Chicago metro area earns its #7 spot with long commutes (31.1 minutes each way, average is 27.4) and working more hours per week than average. Chicago also ranks high for stress (with an unemployment rate of 9.7%, average is 7.5%, plus alcohol use is high with 15.1 drinks per month reported, compared to an average of 12.7 drinks), sleepless nights (8.0 nights per month with poor sleep, average is 7.7), extreme temperatures and particulate pollution is in the top 20%.

For 2016 the top (worst) ten wrinkle rankings were the same as 2014. Predictions for 2040 show a different ranking.

The Dangers of Sun Exposure
Skin Cancer
Dr. Aaron Stone - Plastic Surgeon Los Angeles
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4 Types of People Who Should Not Have Plastic Surgery

November 24, 2016, 12:14 am

≫ Next: Pilonidal Cyst - Pilonidal Sinus

≪ Previous: Skin Aging and Wrinkling by City and State

Nothing left to fill or do
Copycats

Doctor shoppers
Fit specific profiles

Body Dysmorphic Disorder (BDD) and Plastic Surgery
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Pilonidal Cyst - Pilonidal Sinus

December 11, 2016, 2:43 am

≫ Next: Non-Surgical Treatments Cannot Replace Facelift Surgery

≪ Previous: 4 Types of People Who Should Not Have Plastic Surgery

Pilonidal cysts or abscess are located over the tailbone where the buttocks meet on the lower back. The cause is believed to be ingrown hair(s) and/or a congenital pilonidal dimple. Pilonidal is Latin for nest of hair. Excessive sitting or pressure on the area is thought to be a predisposing factor. They cause pain and tenderness over the area with itching and opaque yellow (purulent) or bloody drainage. It was first described by the Mayo brothers in 1833. The disease affects 70,000 people in the United States each year, most of them young men between 15 and 35 years of age. It is 7 times more common in dark skinned individuals, though every patient I have ever treated for pilonidal disease was white. It has historically been associated with the military and even earned the nickname "Jeep-rider's disease" in World War II as it was thought to be due to prolonged jeep rides in bumpy vehicles irritating the tailbone area.

A 2013 study of 151 military personnel afflicted with pilonidal disease revealed that the recurrence rate of the disease is related to the type of surgery used to treat it.

#	Type of Surgery	Complication Rate
45	excision and suture closure	62%
22	excision and suturing wound edges down	27%
69	excision and left open to heal	24.6%
15	incision and drainage	20%

A 2008 study of over 1000 Israeli soldiers had a recurrence rate of only 16% using the trephine technique and 9 year follow up. Almost 90% were healed at 4 weeks after surgery vs. the months required for healing if left open to heal or the edges are sutured down. Other advantages of the trephine technique are less pain after surgery and a quicker return to work. The best options are therefore excision and flap closure or the trephine technique.

Negative Pressure Wound Therapy
Aaron Stone MD - Plastic Surgeon Los Angeles
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Non-Surgical Treatments Cannot Replace Facelift Surgery

December 19, 2016, 7:41 pm

≫ Next: Angioedema and Cosmetic Surgery

≪ Previous: Pilonidal Cyst - Pilonidal Sinus

157 patients under the age of 50 who underwent their first face lift at the New York Center for Facial Plastic and Laser Surgery between January 1, 2003, and December 31, 2013 showed that prior to that facelift each patient spent on average a total of $7,000 on nonsurgical treatments. These included fillers, laser, radiofrequency and botox treatments. The patients reported that they appeared 4 years younger after their nonsurgical treatments, but appeared 8 years younger after their facelift. The take home lesson is that nonsurgical treatments are not a replacement for facelift surgery and that is even more true of patients in their 60s and 70s.

Despite that and correcting for the 2008-2009 recession between 2007 and 2015 the population increased by 6.3% while the number of facelifts per year increased by only 6.1%. The percentage of the population undergoing facelift surgery appears to be a relative constant.

How Long Does A Facelift Last?
Face and Neck Lift 1
Face and Neck Lift 2 Dr. Aaron Stone - Plastic Surgeon Los Angeles
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