For many of us it is hard enough to achieve a work life family balance, much less take time for personal needs. We might enjoy the benefits of plastic surgery but have trouble finding downtime for it. As fewer people have taken time for aesthetic surgery during the recession, there has been a rise in popularity of non invasive cosmetic procedures. Minimally invasive techniques have become a maintenance routine for aging faces.

For those interested in improving skin quality, there is a new product that I like, the VI Peel. I tried it on myself a couple of months ago. This medical grade peel is a light peel that requires minimal downtime and creates little interference with your daily obligations. 

The Vitality Institute Skin Care System has produced the VI Peel to decrease fine lines, fade age spots or sun damage and improve acne scarring. The peel also promotes collagen and elastin growth. This results in better skin clarity and texture and younger looking skin. The procedure takes a few minutes in our office. Your skin turns red like mild sunburn and peels within three to seven days. It can be used on all skin types including Afro Americans and Asian skin. The peel removes the damaged upper layers of skin and repairs from new cells below. 

The peel has a combination of peeling agents that enhance one another. TRICHLOROACETIC Acid (TCA) penetrates the skin. RETIN a causes a rapid turnover of skin cells to reduce wrinkles. SALICYLIC ACID is an exfoliant. PHENOL is antiseptic and helps numb the skin. VITAMIN C is an antioxidant and an exfoliant. 

The peel does not replace a facelift if that is what you need, but it can make a great difference in your skin quality without missing a day of work!

Medical therapy for aging skin can reverse some of the cellular damage that has occurred and create a healthier, younger looking skin.

The American Board of Plastic Surgery continues to be the organization that sets high standards for the type of training, and the demonstration of competence for Plastic Surgeons. Board Certification in Dermatology or Otolaryngology is not plastic surgery. Those calling themselves plastic surgeons are “alternate” practitioners of the art. 

The New York Times January 31, 2012 Health Section described how non-specialists have expanded into the field of cosmetic surgery.  Visit Non-Specialists Expand Into Lucrative Cosmetic Surgery Procedures – NYTimes.com for their discussion.

If you want to know if your doctor is certified by the American Board of Plastic Surgery, you can visit www.certificationmatters.org.

Colleen is 48 years old, in the prime of her career, and particular about her appearance. Her face has changed as she has aged. The lines and sags create a tired appearance when she actually feels energized. Botox and chemical peels have erased a few wrinkles, but she has been wondering whether this might be time for a face lift to keep ahead of the curve. Should she do it now before her changes become extreme or wait until she can really tell more of a difference. If she waits until she is older will the result last longer?

A recent study published in Plastic and Reconstructive Surgery (Vol 129.no1.p263) looked at the age a patient chose to have a facelift and compared it with their long term satisfaction and results. The results were surprising. Younger patients had longer lasting effects from their surgery and were more satisfied. Independent surgeon rating of the results also favored the younger patient.

The women in the study were grouped by age, under 50, 50-60, and over 60. The over 60 group consistently rated their early and long term satisfaction as lower than those in the two younger groups. The surgeons examined before and after photographs of these women to see if the facelift provided long lasting consistent change in five areas.

1. The junction between eyelid skin and cheek skin
2. The fold from nose to corner of the mouth, nasolabial fold
3. The fold from corner of lip to jaw line, “marionette” line
4. The jowls, excess skin that hides the jaw line
5. Neck muscle bands and extra fat

A minimum of ten years of follow up was required to be part of the study. Women who had undergone facelift before the age of 50 had maintenance of their youthful appearance for many more years than those in the two older categories. The surgeon’s observation of the 5 anatomical areas was consistent with the patient satisfaction survey.

So Colleen might well choose to have the facelift she is considering for her early signs of aging so that she will have many years ahead to enjoy its benefits. The “maintenance” facelift while tissues are healthier has been shown to be more long lasting and more consistently satisfying both at year one and year ten.

Visit my gallery

Learn more about facial procedures

How Much Younger Does a Face Lift Make You Look?

1. Where is the breast located on the chest wall?  The base of the breast (breast disc or footprint) should meet the chest wall in a way that is the foundation for the overlying three dimensional structure of the breast. This footprint is constant throughout life. An abnormal location of the footprint or an irregular chest wall can interfere with the aesthetics of the breast. Is your breast fold too high or too low?  Is your spine straight?  Does one side of the chest project more than the other?  Are your ribs crooked? 
2. What is the shape or “conus” of the breast? Breast shape varies widely among women and quite a bit over a given woman’s lifetime. In adolescence the breast is cone shaped. Over time there should be a progressive transition with a greater portion of its volume resting in the lower outer quadrant. The nipple should be at the area of maximum breast projection, roughly at the apex of the cone shape. 
3. What is the quality and quantity of the breast skin? Too much skin leads to a drop in the breast position on the chest wall. The skin provides the major support for the breast gland. If elasticity is poor, the skin envelope cannot contain the gland in a suitable shape.
4. Is the areola size a good match for the volume of the breast? Is the nipple position correctly located on the projecting portion of the breast and in the middle or slightly lateral to the middle of the breast?
5. Do the two breasts look alike? Most women’s breasts are more like sisters than identical twins, but symmetry is one feature of the hoped for end result.
6. Is the volume appropriate for the rest of the body’s proportions? You should express your size concerns to your surgeon and have a careful discussion about any possible downsides to your choice. 

Tubular Breasts

The term “TUBULAR” refers to SHAPE for a tubular breast. It is used to describe a breast shape that is long and narrow, rather than being broad at the base with a gradual decrease in width up to the top, like a cone or pyramid. Women that have tubular breasts often have a very high fold at the base of their breast, and they have puffiness in the nipple-areolar region where the breast seems to bunch out of the top. A mild tubular breast shape is quite common. Extreme tubular breast deformity can be very troubling  to have, and women often want the shape improved.

Visit my gallery

Find out about breast procedures

The Impact Honduras project has targeted twenty-four communities located in remote areas of the mountains of central Honduras. The goal is promote sustainable change among the poor by providing basic healthcare, with extended healthcare services for special needs children and pregnant women. The program designates community health care providers, assists in water purification, health education workshops, trains midwives and promotes leadership development. 

Our team consists of 15 people, two pediatricians, one surgeon (me), two nurses, an optometrist, four translators and pharmacy specialists and team leaders. Each day we will be visiting one of these targeted communities to screen for health problems among the children, educate about health issues, and provide basic care to all that request it. Children with severe problems are referred elsewhere for more complex treatments. The Friends of Barnabas also provide cardiac surgery to children with congenital heart conditions and plastic surgery for children with cleft lip and palate.

The Friend’s of Barnabas Foundation’s mission is to improve the lives of the Honduran poor by providing high quality sustainable medical care and enabling communities to become self sufficient through health related training and education.

You can learn more about Impact Honduras or make a donation by visiting the website www.fobf.org.

I will be documenting my trip with my daughter Sarah, my Spanish translator, on my Facebook page in January 2012. 

The Nov 24, 2011 NEW ENGLAND JOURNAL of MEDICINE published a randomized controlled study in 415 obese people to compare two different approaches to supporting WEIGHT LOSS. All patients were followed by their doctors for a two year period. One group of subjects had weight loss coaches that provided in-person support with both group and individual sessions. A second group had its counseling provided remotely by e-mail, phone or web site. The third group was entirely self directed without supplemental advise or support.  

The self directed (non-supported) control group had a mean weight loss of .8 kg, not much change at two years. The two groups that received support both were able to maintain a 5% weight reduction. This modest weight loss is a good start on decreasing cardiovascular and diabetic risk even if it is still a far distance from being at ideal body weight. The group with face-to face coaching did slightly better than those who received their support on line, but support was critical.

The take home lesson is that lifestyle changes are hard to maintain especially when attempted all by yourself.  Education and encouragement make a difference in being able to sustain change in habits. You may lack both time and money for one on one coaching, but taking advantage of on line support systems may be a very good method to reinforce behavioral modifications. Most health clubs offer a supervised program to track diet and exercise. There are multiple web sites for monitoring calorie intake and exercise to track progress in those key behaviors. Here are a few you might find helpful:

www.healthdiscovery.net – Weight Watcher’s Support Network

win.niddk.nih.gov/ – Weight-Control Information Network

www.obesityhelp.com – Web site with resources for surgical weight loss

www.overeatersanonymous.org – Successful group based on the 12 Steps model

Don’t forget to keep moving!

Men that are uncomfortable in the locker room or at the beach may be those whose chest appears more like an adolescent female than a male. Male breast enlargement, called GYNECOMASTIA, is common and can be a source of embarrassment.

Recently a 16-year-old boy came in with his parents to talk about his gynecomastia. Brian had become increasingly unhappy at school. He socialized less comfortably than he had as a little boy and he refused to participate in sports. He spent more time alone playing computer games and had put on a lot of weight. At 5’8″ he was 225 lbs. He had trouble losing the weight because he was humiliated to take his shirt off in front of others and did not want to participate in sports. Teenage boys at school targeted him as the brunt of their jokes.  

Brian had a very extreme case of male breast growth that was made worse by his weight gain. His embarrassment was understandable. He had been evaluated at the Children’s Hospital endocrinology clinic and no cause had been found for the breast enlargement. He and his parents wanted to remove the stigma as soon as possible.

Brian’s surgery incorporated a variety of surgical techniques. LIPOSUCTION of the chest wall helped to smooth the contour with removal of the extra fatty component. The dense glandular tissue was removed through a small incision camouflaged at the junction of normal skin and the brown areola, a variation on a SUBCUTANEOUS MASTECTOMY. The TUBULAR BREAST shape was corrected by a PERIAREOLAR MASTOPEXY, which means that extra skin was removed and constricting fibrous bands were removed to reshape his chest.  

Brian had an enormous sense of relief immediately after his procedure. He is more confident and outgoing and relieved of the sense of shame he felt about his chest. He is hoping to tackle his weight issue next.

What Causes GYNECOMASTIA?

Male breast enlargement happens commonly at two times in a man’s life. At mid to late puberty there can be an excess of free ESTROGEN before adult levels of TESTOTERONE have been produced. Breast enlargement at this phase goes away within a year 95% of the time. If it lasts longer, it is likely to persist unchanged. The second time that breast enlargement is common is in late life as testosterone level is falling. 50% of men have decreased free testosterone by age 70.  

The vast majority of the time no cause can be found for gynecomastia. Rarely there may be tumors of the testes or adrenal that produce feminizing hormones. Failure of the testes to produce testosterone can also result in breast growth. Obesity can be a cause of gynecomastia as increasing BMI results in converting adrenal hormones into estradiol, which stimulates glandular growth.

Men with severe liver failure, kidney failure, and hyperthyroidism can all be associated with benign growth of the male breast.

There are a number of medications that have been known to stimulate breast growth, including certain diuretics and anabolic steroids.  

There is not complete agreement on whether or not biochemical studies should be ordered for the evaluation of gynecomastia, because the tests have a low yield. The cause is usually found with a careful history and physical exam. Medications including estrogen inhibitors have been largely unhelpful. If the gynecomastia has lasted for more than a year, then surgical removal of gland and fat improves their appearance.

Reference: New England Journal of Medicine 357;12 p.1229.

Not all addictions are bad, but this one is believed to be related to the 30% rise in the rate of melanomas with the biggest increase among women 15-39 years old. Melanoma is a skin cancer that arises in dark colored skin growths. It can be cured if caught early, but results in a devastating course if spread has occurred. The risk of death from advanced disease remains high. Researchers estimate that the increase in incidence of melanoma is related to tanning bed use.

The New England Journal (NEJM 363:10,p901)  has a good description of how the same mechanism that causes your skin to tan is resposible for DNA damage that sets the stage for skin cancer development. It is theorized that tanning may be the body’s attempt to protect itself from the damaging effect of radiation. When DNA is damaged the skin is programed to release melanin, a brown pigment that can help filter the sun’s harmful rays. Tanning cannot occur without DNA damage. If your body does not repair that damage, you may be subjecting yourself to a cancerous change.

There are public health advocates that believe that regulation or even banning of tanning beds might be an opportunity for public safety. Multiple European countries have started to enact restrictions on tanning beds. Whether or not that occurs as a legislative agenda in the US, you can protect yourself by selecting a quality spray tanner and avoiding unnecessary exposure to ultra violet radiation.

So if you like the look of that outdoor ruddy complexion head for the cosmetic counter instead of the tanning parlor and get your endorphins with a brisk work out.

Questionnaires were distributed prior to surgery that consisted of measures of satisfaction with appearance, self-esteem, psychological problems and patient’s evaluation of the outcome of surgery. The questions included well validated and widely used psychometric measures. The questionnaire was repeated at six months and five years. The same questionnaire was sent to a control group of 838 patients who were aged matched but had not had plastic surgery. The 130 patients included in this study had chosen, breast enlargements, breast lifts, liposuction, tummy tucks and eyelid operations. At five years:

92.2% of patients considered their appearance as good as they expected or better.

81.4 % were more satisfied with their overall appearance.

89.2% thought that the body part operated on had improved in appearance.

93.8% said they had no regrets about choosing plastic surgery.

89.9% said they would choose plastic surgery again if faced with the same circumstances.

Satisfaction with appearance was greatly improved. However, little or no improvement was seen in self-esteem and mental health. Other interesting observations of the study were that patients were most satisfied when they had taken a long time making their decision for surgery rather than acting impulsively.  Patients were also more satisfied when doing the procedure for themselves rather than for the sake of a loved one. Those with psychological or self esteem issues before the surgery reported more negative changes in their psychosocial function postoperatively. 

According to this evidence based study you might conclude that plastic surgery does not fix deep seated psychological issues, but it can make you feel a great deal better about your appearance.

Yo-yo dieters know the disappointment of working hard to achieve a weight loss goal and having the progress fade away as soon as the discipline is relaxed. What makes it so difficult to stay at a stable weight once the pounds have been shed? The October 27,2011 edition of the New England Journal of Medicine (vol.365. No.17 p1597) provided a valuable study that provided some clues to the metabolic explanation.  Researchers from the University of Melbourne in Australia published their study of 50 overweight men and women that were enrolled in a 10 week calorie restriction weight loss program. Hormones were measured before the diet, at 10 weeks, and one year later. The hormones they examined were those known to be responsible for appetite control. These substances are released from the gastrointestinal tract, the pancreas, and fat stores. The hormones circulate to the hypothalamus in the brain where they regulate food intake and energy expenditure. When caloric restriction begins the body increases the output of hormones that create hunger and decrease energy expenditure. In other words these hormones fight to keep the weight on as you struggle to keep it off. If we lived in an area of famine this would be adaptive. In our culture with an overabundance of food, it is difficult to turn off the system that is counter productive in the modern world.

The researchers found that at 10 weeks the dieters had lost an average of 13.5 kg or 14% body weight. One year later they had regained an average of 5.5 kg so that their weight loss from the beginning was only 8.2%. The hormones of starvation were all increased at week 10 and one year contributing to the creep up in weight. These hormones had not returned to normal levels even as weight gain was occurring. A strong physiologic basis appeared to be the cause of regaining weight rather than voluntary resumption of old habits.

These studies will allow researchers to focus on ways to alter the appetite controlling hormones.