Posted on January 26, 2010 in Uncategorized, interesting & new
Herbal supplements are medications. As I have said in my other posts, just because it is “natural” and you don’t need a prescription, does not mean it isn’t a strong medication. I am still stunned when medications get labeled as “supplements” instead of medications, so they bypass the FDA. The FDA requires pesky things like proving they are safe and effective at what they claim. Instead, herbals fall under the Dietary Supplement Health and Education Act of 1994, so they are regulated with the food.
Anesthesia is an important part of having a surgery. For some of my patients, it is likely the only uninterrupted sleep they have had for a while. I respect the anesthesia risk. My patients have elective (ie they choose to do it), scheduled surgery. For many it is cosmetic. Most of my patients are moms. The safety bar for me is high. It should be high. I only operate in accredited centers, and for general anesthesia I always use a board certified anesthesia doctor.
The anesthesiologists use a combination of IV medication and gases to put you to sleep. They change the dosages based on your weight, length of surgery, etc. Herbal medications can affect the medications they use, by changing the heart and blood pressure dynamics, the liver metabolism of the drug, and other effects. BAD.
EPHEDRA (MA HUANG)
This is an ancient Chinese medication. It is a known stimulant, which constricts blood vessels, increases heart rate, increases blood pressure, and is “thermogenic” (increases metabolism). This was a common weight loss drug. It has also been used for asthma, hay fever, and to increase general “energy.” There are many known severe reactions to this drug. The New England Journal of Medicine in 2000 had a study showing sudden heart attack and severe disability in young people who were taking the drug within the recommended dose. (!!!!) Side effects are many: nausea, dizziness, seizures, heart attack, stroke, and heatstroke (see Steve Belcher and Korey Stringer, both pro athletes who died from heatstroke, likely after using ephedra for its “performance enhancement.”)
SO. This herbal medication is NOT benign. Surgery is a stress. I liken it to running a marathon. In healthy people who are not having surgery, ephedra causes issues. This herbal is well documented to cause heart attack, stroke, heartbeat irregularities, blood pressure issues, and body temperature issues. Supposedly the effects wear off quickly, but this is an herbal proven to be deadly when taken as prescribed. Not worth it.
KAVA
This is a drug from the root of a pepper plant, known to reduce anxiety and cause sedation. Issue? During surgery anesthesiologists use drugs to help patients relax, like Valium, Xanax, and others. Kava augments the action of these other drugs, and it sticks in your system for a while. You may think sedation during surgery is good, why not have more? The issue with oversedation is primarily breathing. If you are too sedated, you don’t breathe.
VALERIAN
Many herbal sleep aids contain valerian. It is also used as an anti-convulsant, migraine, and pain reliever treatment. It acts just like Valium. If you have used it for a while, you can withdrawal if you stop it. It also interferes with sedatives used during anesthesia.
I can’t repeat it enough- herbals, diet pills, and supplements are medication. You need to treat them as such. Please tell your doctor about them before your surgery. And for most, I strongly recommend stopping them 2 weeks ahead of surgery.
Posted on January 19, 2010 in Skin / Nonsurgical, Uncategorized, interesting & new
Yup.
Herbals are medications. In general, ones which are “heart healthy” and help you with atherosclerotic disease, peripheral vascular disease, impotence, or have anticoagulation properties = MAKE YOU BLEED. Seems obvious, but sometimes it is hard to think herbals are medications, and you may be taking an herbal for a different effect, like depression, and not know it is also an anticoagulant.
Common ones:
GARLIC
No, if you eat garlic bread at dinner you aren’t going to bleed to death if you get a cut (even if you go to the Stinking Rose in San Francisco). Garlic has been used as a medical remedy for thousands of years. It lowers cholesterol, reduces blood pressure, and inhibits thrombus formation (it inhibits platelets which help blood clot). The risk is dose dependent. Again, the amount in food is low. You are at risk if you take a specific supplement.
GINGKO BILOBA
Gingko comes from a unique species of tree located in China. It was thought to be extinct, but preserved by cultivation by Chinese monks for 1000 years. Gingko is used for a grab bag of indications, including improving memory and concentration, vertigo, dementia / Alzheimers, MS, and blood flow / microcirculation. Some of its effect is due to improving microcirculation and its antioxidant properties. Again, like garlic, it impedes platelet formation of clots.
GINSENG
Yes. The G herbals make you bleed. Ginseng is a staple of Chinese and Native American medicine. It is supposed to help the body fight stress and increase energy. It is also thought to help with libido and other hormonal and reproductive issues.
Issues for surgery? It has been said to increase coagulation time. Also, it may decrease blood glucose, which can be an issue for surgery patients who are not allowed to eat prior to surgery, particularly in diabetics. It can also interact with other drugs, including insulin, NSAIDs, anticoagulation drugs, blood pressure medications, and MAO inhibitors.
GINGER:
Thought to help with digestion and as a stimulant. It prolongs the action of some anticoagulation medications, and is supposed to have blood thinning capabilities.
ST. JOHN’S WORT
This drug is commonly used to treat depression. In some countries it is a prescription. ?It is thought to have anticoagulation properties. It is well known to cause increased metabolism of drugs and increased liver activity. This can lead to medications used in surgery not being at the appropriate level, as they are metabolized too quickly (and for you younger women out there, this includes birth control pills! women experience breakthrough bleeding because the blood levels of the birth control pill are too low). And in some medications like Plavix (a blood thinner) it amplifies the medication, causing an increase in bleeding time.
OTHERS
Alfalfa, capsicum, celery, chamomile, Chinese herbs, fenugreek, feverfew, fish oil, ginger, ginseng, horseradish, kava, licorice, passionflower, red clover and Vitamin E, meadowsweet, willow bark, tumeric, and bilberry.
There was a case report on echinacea- commonly used for colds- which caused bleeding in a woman who used it chronically. How? Her chronic use likely lead to liver issues, which caused the bleeding problem.
SO.
Remember herbals are medications. Tell your doctor what you are on, and likely stop them for two weeks ahead of surgery (at least if you are my patient). But that extra piece of garlic bread is okay.
Posted on January 15, 2010 in Skin / Nonsurgical, Uncategorized, interesting & new
Just because it is “herbal” and natural, does not mean it is safe.
Vincristine, a chemotherapy agent, comes from a common garden flower.
Herbal supplements are common, particularly here in the Bay Area. They are in everything: single pill diet herbal supplements, power drinks, teas, diet pills, and muscle building supplements. I joke it is probably in our water too. There are many issues with herbals.
- They are not regulated as closely as prescription medications, so you don’t know exactly what is in them. I saw an expose once on asian herbs, where they had taken them to a lab and analyzed the content. They found high levels of arsenic in one brand. Of course, the arsenic wasn’t listed on the “ingredient” list.
- People don’t think of them as being medications. On my sign in sheet, I ask what medications including herbals the patient takes. Even with that, many patients don’t mention herbals and vitamins until I specifically question them.
Why does it matter? Because some herbals make you bleed- a bad quality during many of my surgeries. Some interfere with anesthesia. And they can affect other systems: I had a patient who was in liver failure due to an “herbal supplement.” She had no idea. We discovered it when routine preop labs showed her liver function tests were through the roof and her platelet level (which helps you clot to stop bleeding- again a good quality during surgery) was low. Eeek! She was a healthy younger woman. Those labs made us think of liver failure, infections, cancers- we were thrilled to find it was just the herbal medication, and her functions returned to normal after stopping the herb.
It takes time to get the herbal medication effect out of your system. I have my patients stop all herbal medication two weeks prior to surgery, and I don’t let them restart until they are 2- 3 weeks out. There are some herbals which are okay, but you need to clear each individual one with your surgeon prior to surgery.
SO
Herbal medications are MEDICATIONS.
They can have a profound effect on your body.
Discuss them with your doctor prior to surgery.
Posted on January 12, 2010 in Skin / Nonsurgical, Uncategorized, breast cancer, interesting & new
Vitamins.
They are good for you. Is more better? What happens when you take more? Do you pee it out? Or does it help you heal better?
When looking into this, I went to the scientific articles, not the press. I do take things with a grain of salt: all scientific papers are not equal. Was it a good study with adequate numbers and controls? etc etc.
So. What did I find?
Wounds are harder to heal for some people:
- Age
- Steroids
- Radiation
- Chemotherapy
- Diabetes
- Smoking
- Poor nutrition
As a surgeon, I see the effect of poor blood flow causing wound healing issues. Diabetes, smoking, high cholesterol, exposure to cold. These are not important for small cuts. But when we do “flap” surgeries like breast lifts, facelifts, and tummy tucks, blood supply is critical.
One good study I saw stated the most important factor was not a vitamin level, but your protein level. They found if your serum protein was less than 6g/dl, you would not heal well. They did not see a correlation with Vitamin C, Vitamin E, or anemia. (I was suprised by the anemia part- you need blood to bring the oxygen and nutrients to the wound to heal.)
Vitamin A:
Vitamin A stimulates the early inflammatory resonse to healing (which is good- it’s like the paramedics have arrived). A deficiency causes impaired collagen synthesis. In normal people, taking extra Vitamin A likely does little. The place Vitamin A is well documented to help is in those on steroids. Steroids, like Vitamin E, inhibit healing. They measure this by looking at the tensile strength of the wound, ie how easy is it to break open?
A normal dose is 2000-3000 IU/day. When trying to do a supplement to help with healing, the dose is 25000 units. This should be done for a short period of time 1-2 weeks. High doses of Vitamin A are not good if trying to have a child, or if you have a history of liver disease.
Vitamin C:
We all know about those scurvy pirates AAARRRH.
One of the original papers I found supporting Vitamin C and wound healing was a 1937 paper, so this is not news. Vitamin C is needed to make collagen. It is also an antioxidant and thought to strengthen the connective tissue in skin, muscle, and blood vessels. When you don’t have Vitamin C, you get scurvy. Scurvy presents with skin lesions and bleeding from mucous membranes. People look pale, can lose their teeth, and are depressed. We humans lack long term storage for Vitamin C.
What dose? Normal daily recommendation is 60 mg/day. If you lack Vitamin C, they can recommend up to 1-2 grams a day. A typical wound healing dose though is likely around 500mg.
Vitamin E:
Aaaaah. This is such a tricky one. Vitamin E is a strong antioxidant and helps your macrophages work (fighters who eat up bacteria and invaders and call in more troops to fight infection).
BUT I make all my patients stop Vitamin E before surgery. Why? 1. Because it makes you bleed. The normal amount in your multivitamin is okay. The 400 IU is not. 2. At higher doses it can inhibit collagen synthesis and decrease tensile strength of wounds, just like being on steroids.
I get a lot of push back on vitamin E. “I hear it makes scars better.” It weakens scars. The only scars it “makes better” are those which are hypertrophic or keloid. For a normal scar, you don’t want to weaken it. It has just the right amount of scar and strength. If you weaken a normal scar, it will indent or widen. So for “good healing” I don’t recommend more than what is in a typical multivitamin.
SO to sum it all up, for normal patients you likely don’t need any supplements. You will heal just fine. If you have any issues on the list of healing issues, then consider supplements (after you clear it with your doctor of course).
Yes, Protein. Yes, Vitamin A. Yes, Vitamin C.
No Vitamin E.
Posted on January 8, 2010 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast augmentation, breast implant
Americans love to supersize. 
Big cars, Supersized fries, the super big gulp. But bigger is not better when it comes to breast implants.
I answered a question from a patient who had been an AA her whole life. She was teased and felt self conscious. So she decided to do breast augmentation. Her surgeon (not me, but easily could have been) told her he would not do a breast augmentation to make her a DD or larger. She was “shocked.” “Lots of women get breast implants WAY bigger than a DD, so why am I being told me request is unreasonable?”
Hmmm. I can understand her frustration. Implants cost the same, regardless of size…. If I get a 500cc implant instead of a 300cc one, I got 200 cc more for the same cost. Woo hoo, eh? This is my body, and if I want a DD, then I will get one! Hmmm. She can go to another surgeon. I’m sure she’ll find someone who will do it. But I think she is bothered by this because the surgeon she saw seems principled and experienced. She knows he is right.
Why would a doctor talk her out of a big size?
Many of us see our long term results years down the road. It does change the way we do things, and how we advise our patients
1. When you are thin, you have thin tissue cover over the breast implant. My skinny athletic Northern California women don’t have much padding. Whatever padding you start with gets thinner over time, as the weight and width of the breast implant thins it more. What does this mean in English? It means as your soft tissue padding thins, you will droop, potentially bottom out, and see wrinkling and other implant abnormalities.
2. If you go to a super large size, even if I put you in the narrowest implant, a high profile, it will be too wide for your chest. What does this mean? It means you will hit your breast when doing any movements along your side, like golf and tennis (what is the handicap for that?). It means your tissue on the side of your breast thins, and you will look round, shiny skinned, and again will see wrinkling.
3. The weight of the implant will cause you to droop. The implants come as cc measurements. The cc’s tells you the number of grams the implant weighs. Simple science: The heavier the implant, the more it weighs, the more you will droop with time. (Unless you live on the moon.)
4. The weight of the implant can cause back and neck pain, shoulder notching (where your bra straps go), and poor posture. See the issues large breasted women get, and why women who are a D, DD, on up come in droves to get lifts and reductions.
5. They will look bad. Unnatural. Round. Fake. Not pretty at all.
6. If you think you want it that large, wear it around for a while. This is more girlfriend’s advice, not a plastic surgeon’s, but do you want that kind of attention? Always? Try to jog. Try on shirts which button up. Try to have a conversation with eye contact.
I am not a Pam Anderson kind of doctor. My patients like people to look them in the face, and listen to what they say when they talk. (Oooh. Those ladies with thoughts and ideas…) I know. That was a horrible generalization. But I don’t see many women like this who want to be a DD or larger.
At least not at this point.
I do see many of these oversized implants down the road. Large, thin skinned, brassy, round. Droopy. Back pain. And NOW they want to downsize. This is now a much harder problem. Lifts are difficult when the tissue is too thin. Scars from a lift are much larger than a simple augmentation. And I can’t get the skin to “thicken” again.
So. Take a long term view. Bigger is not always better, particularly in my thin Bay Area patients. Go for a medium size. It’s bigger than what you’ve got. Go for natural, pretty. Go for breasts you can still jog with. And when you wish you were a little fuller on a Saturday night, wear a push up bra, and think how much better your breasts will look at age 60 than if you had blown them out at age 30.
Posted on January 5, 2010 in Face, Skin / Nonsurgical, interesting & new, skin fillers
Thanks to all of you for coming on Thursday for our informational session on Sculptra.
Here are some links to videos on the national news showing the injections: (No, I don’t look to these media outlets for my medical advice, but I do think these are good snippets to show you how the injections are done. There are needles, so don’t watch if you don’t want to see needles.)
The early show on CBS:
http://www.youtube.com/watch?v=dmBtJS-L6VU
Entertainment tonight:
http://www.youtube.com/watch?v=KReow3bFfW4&feature=PlayList&p=F2A53B8B3A22BCF5&playnext=1&playnext_from=PL&index=27
