Posted on March 1, 2010 in Skin / Nonsurgical, products
VIVITÉ® Vibrance Therapy is made with natural ingredients. I like things with science behind them, and this product is an alternative to hydroquinone products for those with pigmentation and sun damage. There was an article in Cosmetic Dermatology, 2008 showing UV damage correction was similar to a 4% hydroquinone.
The goal? In addition to the pigmentation, its goal is to
1. help brighten
2. even skin tone
3. help reduce appearance of fine lines and wrinkles
with visible results seen in just 8 weeks. “Restorative, antioxidant-rich cream works to help even out skin tone without hydroquinone.”
Key ingredients:
GLX TechnologyTM, superoxide dismutase, methyl dihydroxybenzoate (reduces pigmentation), licorice root extract, mulberry fruit extract, grape extract, green tea extract, lycopene, olive leaf extract, fennel seed extract, vitamin C, vitamin E, retinol, soy isoflavones. Contains 15% glycolic compound.
To be used once or twice daily. For daytime use, apply after you have cleansed your skin.
1. McDaniel DH, Wu J. Efficacy of a natural-based bleaching cream versus hydroquinone 4% bleaching gel in the treatment of hyperpigmentation. Cosmet Dermatol. 2008;21(11):596-602.
Posted on February 1, 2010 in Skin / Nonsurgical, interesting & new, skin fillers
Both products are offering goodies right now.
Juvederm is offering a free Vivite lip plumper ($45 value) when you use a syringe.
Restalyne and Perlane are offering $50 back for every syringe you use.
Woo hoo! Call the office for an appointment. These are great fillers for the tear trough, cheek, nasolabial fold (the parenthesis around your mouth) and your lips (yes,don’t worry, you don’t have to look overplumped and ducky when it is done well.)
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 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
Posted on December 15, 2009 in Face, Skin / Nonsurgical, interesting & new, skin fillers
Volumizing isn’t just for hair anymore.
There was a big shift in plastic surgeon thinking about a decade ago.
Look at the eyelid. We used to remove fat when doing lower eyelid surgery. The thought was remove the bulge, and the eye will look youthful. But the face doesn’t work that way. As you age, you lose facial fat. (Yes yes, you gain it elsewhere where you don’t want it.) As you lose fat in your cheek, you look hollow under the eye, your lower eyelid looks longer, your cheek pad drops, you get lines around your mouth which deepen (stop! stop!) and your face skin slackens. (oy! can you stop already?)
But this is what happens. So fast forward to now- the new generation- no scar, nonsurgical, fill fill fill generation. There is validity to it. I am a surgeon. I love to do surgery. But I saw a patient yesterday who has lost weight. She also exercises more, causing a lower body fat percentage (yes, for those of you with the wee ones, there is hope for us yet to see a gym again.).
She has loose skin.
She would benefit from a facelift. Her skin is loose from age and weight changes. But as I showed her in the mirror, even when I tighten the skin, she is flat. Hollow. The “deflated beach ball.” She needs volume. So instead of rushing to surgery, I recommended she try filler first. To get the result she wants, she must correct the hollowness. She should add volume first (nonsurgical, cheaper, no scar, minimal downtime), and then reevaluate. Adding volume will buy her time, even years, before she wants to do a surgery.
What filler to use?
For first timers, immediate gratification people, and small areas, I like restalyne/perlane or juvederm. For those with higher volume needs who want a longer lasting fill, I like sculptra. Volume doesn’t have to be a overly plump fake look. As with all plastic surgery, when done elegantly and well, it looks seamless. The goal is the “How do you look so good for your age?”, not the “Oh my. did you have a fight with a helium tank?”
So. Pump up the volume. It works.
Posted on December 10, 2009 in Body, scars & scar care, tummy tuck
The belly button.
It has no use after you are born, yet we are quite obsessed about it. Are you an innie? Outie? Many of my young patients pierce it. Many of my moms have one which “winks” after being stretched by babies. Some pregnant women get a small umbilical hernia, so the innie is now an outie.
Egads! When that happens I think you need counseling.
Such a small thing. Such big issues.
Belly button shape after a tummy tuck is a tough thing. I recently fielded a question from a patient who has a slit like belly button after a tummy tuck. That can happen. If your belly button is pulled, it can look stretched.
How can you make a belly button look pretty?
When we do a full tummy tuck, you have a scar going 360 around the belly button. We doctors do all sorts of little tricks to try to tuck the belly button, get it to indent, and hide the scar. I went to a talk once on “aesthetics of the belly button” at our national plastic surgery meeting. (Yes, yes. These are the kind of talks we go to as plastic surgeons.) But belly buttons are important. The belly button shape voted “the best” by the study was slightly hooded on the top and fanned out a little on the bottom.
I try to simulate this. Most of my patients look great. I have patients who’s scars overall are fantastic- hairline, barely visible. If your belly button doesn’t look great, what happened and what can you do?
If your belly button looks too small, it contracted on itself because it is a round scar. I changed the way I inset the belly button to improve this by creating a little advancement flap into the belly button. Also you can try the marble trick to enlarge and round it out.
If your belly button formed a raised scar (keloid or hypertrophic scar) you can try scar creams, massage, silicone gel sheeting, steroid injections, and cutting it out and starting again. In general, I always try to close under little tension. Tension is bad and can lead to raised scars. Keloids though tend to happen more often along the midline. And belly buttons tend to be in the midline.
Funny belly button shape. I find women who are super skinny and have no fat around the belly button are tougher to get pretty belly buttons in because they don’t indent as much, and it is harder to hide the scar. The toughest are women with no indent anymore, where the belly button looks like a shallow saucer. These women are tough as they have blown out their belly button.
But I try. Because what point is having a beautiful flat tummy if you can’t show it off a bit?
Posted on December 2, 2009 in Face, Skin / Nonsurgical, products
Yes, that was not a typo.
I do love skiing, and clearly winter is ski season as well. But as I am a plastic surgeon and not a world famous downhill racer, I am here to tell you winter is prime time, the best time, to improve your skin. Why? Mostly because it is dark, and you aren’t out in the sun, a great thing when trying to get rid of the skin pigmentation caused by the sun.
My favorites for winter:
Retin A products. (Differin, Tazorac, Refissa, Renova) These are not over the counter- they are prescription and not baby safe (sorry for all of you Bay Area moms with the wee ones). The issue with Retin A products is they can make your skin a little red and peely. Not good for summer, but in the winter, AHA! I just tell people I went skiing and got a little windburned (though windburn is likely really a form of sunburn). What does Retin A do? It thickens your dermis (skin) and makes the collagen more organized (which is good). It is tried and true, old old technology which works. Put it on at night. Avoid the sun. If you get too peely, then lower the strength and/or do it every other night.
Peels. TCA, Blue peel. I love it. It is a controlled chemical burn which removes the top layer and a half of your skin.
(Yes, should only be done by a doctor professional. I recently fielded a question from someone who found a kit on the internet to do a home peel. eeek! Some acids are weak- like the fruit acids- so it is difficult to go deep. TCA is not a weak acid, and if you go too deep you will scar and depigment your skin. Bad.) So, back to the TCA. When you go deep enough to do anything for the fine wrinkles and pigment, your skin must resurface. Your skin looks flaky and peely- not red, bleedy, crusty- but you aren’t going to want to be seen by a lot of people as you go through it. The resurfacing process takes 7-10 days. A great lesson to your kids on why they need to put on the sunscreen in our California sun. The skin looks fresh and new after it peels, and you have months before you beat it up again with the sun (and of course, you will now be a big fan of sunscreen daily, yes?). I am a big fan of the peel, and have done it myself. Remember you need a week of downtime and avoid the sun afterwards. Again- walah! Winter is the perfect time. (NOTE: if you are dark skinned, you need to pretreat your skin prior to the peel for a month with Retin A and hydroquinone to insure your pigment will be smooth. Some of my patients get such an improvement from the products, they don’t need to do the peel).
Other good things:
B5 serum- Helps hydrate if you get dry skin.
Antioxidants :C&E. Always good, year round. Skinceutical C E Feurlic and Phloretin CF
Sunscreen: When you do go to the mountains, that windburn is really sunburn. (I know I know. I thought it was just the glow from being in the mountains skiing).
Eyecream: Winter can be drying. Elastiderm helps plump the skin up again.
Hmmm. Think that is about it.
Skin season. It’s on!
Posted on November 23, 2009 in Body, Breast, Mommy Makeover / Body post baby, Skin / Nonsurgical, interesting & new
The government has gone mad.
I get why they would want to tax elective medical procedures. They need money. They have gone wild on spending, and they need new revenue. This new tax is proposed to go into effect January 1, 2010 (!!!).
5%.
They are going to tax every “cosmetic” procedure by 5%. What is truly scary is their definition of cosmetic procedure is broad, and includes whether paid by insurance or otherwise (!!!) Their definition:
COSMETIC SURGERY AND MEDICAL PROCEDURE- ”1. is performed by a licensed medical professional and 2. is not necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease.”
I understand many of the surgeries I do are not going to save the world. So government thinks “Hmmmmm…. we need money. Cosmetic procedures are a growing business. Let’s tax it.” But taxing cosmetic procedures is a slippery slope. When I do a breast reduction and insurance actually covers it as “medically necessary” (which is tough to get covered these days), will this be taxed? When I do a tummy tuck and repair the muscles, so my patient no longer has back pain, is it cosmetic? One of my general surgery colleagues calls the diastasis a “ventral hernia” and insurance covers it. Am I being discriminated against because I call it what it is- a diastasis, not a hernia? Will my patients pay the tax, but his won’t? Oh but wait. They said they will tax it even if insurance does cover it. So maybe they will tax me AND the general surgeon.
WHAT IS COSMETIC? Is having twins which blow out your belly so you look 5 months pregnant every day of your life a cosmetic repair? or is it reconstruction to get you back to where you were, so you won’t have chronic back pain? Do we just need more women in Congress who have had kids, so they can understand us better?
What is cosmetic? Botox patients who do botox injections to treat migraine headaches- cosmetic or not? Instead of living for months headache free, will they, must they go back to medications which they take after they already have the headache?
1. women are the majority of plastic surgery procedures and patients.
2. this tax won’t affect the wealthy. they’ll do things anyway. this tax will affect much of my patient base- my moms, who are in the middle class.
3.Will this create artificial distinctions between specialties? Looking at botox injections- if it is done to treat wrinkles will you be taxed, but to treat headaches it won’t? Will it only be taxed if I do it, a plastic surgeon for their headaches, and not if done by a neurologist?
4. The bill specifically states if done by a medical professional. Will this spur nonmedical people doing injections (an already scary trend)?
This is a horrifying step. Why should my 40 year old woman’s desire for botox be taxed, and a 50 year old man’s desire for medications for his “erectile dysfunction” not be?
Ahhh. the slippery slope. Once they tax cosmetic procedures, do you think others are not steps behind?
Is a hernia repair cosmetic? If a man has a bulge in his groin from a hernia which reduces easily (means it isn’t stuck, and therefore not a medical emergency) is that a cosmetic repair? It is not a congenital deformity, it isn’t an injury from an accident or trauma, and it isn’t disfiguring. I would argue a hernia is no more disfiguring than breasts which touch your waist and cause you incredible back pain, neck pain, tingling in the fingers, and a hunched posture. Oh. But women asked for that when we had kids and breastfed them to make them healthier.
Forget the removal of that mole. Or sebaceous cyst on your cheek. Those are not disfiguring, congenital, or a result of injury.
Do not tax procedures. It will create a slippery slope, it disproportionately and unfairly affects women, and it will cause weird practices and loopholes which have no business in medicine.
