Keloid Scars of the Face and Neck

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 +Vaibhav Shah 

                                  Keloid Scars of the Face and Neck

       Cosmetic facial surgeons frequently see patients with keloid scars.  There are many types of scars.  Hypertrophic scars are those which enlarge within the boundaries of the original scar and keloid scars are those that enlarge outside the boundary of the original scar.  Due to this, keloids can become quite large and disfiguring.  Although any race can develop keloids, they are most common in darker skin types.  The actual cause of keloids remains unknown but they frequently develop as a response to irritation, such as ear piercings, traumatic lacerations or surgical incisions.  Some areas of the body are notorious for forming keloids such as the earlobes or the sternum (breast bone) in open heart surgery incisions.

         Over the years there have been many different treatments for keloid scars.  Although it is tempting to merely excise them, they will most often return with a vengeance, growing larger than the original keloid.

         One of the most simple and frequently effective treatments for keloids is injection with an anti inflammatory steroid such as Kenalog (triamcinalone).  This causes the keloid to shrink and repeated injections can be quite effective in softening and reducing the size of the keloid.  A chemotherapy drug called 5 flourouracil can also be mixed with the Kenalog for even more scar dissolving power.  Sometimes injectable steroids are quite effective and can dissolve the entire keloid.

        Another method of treating keloids is to surgically excise the keloid and begin immediate injection of Kenalog.  I have used this technique on smaller keloids with good success. The most effective method for treating larger keloids is to surgically excise the keloid, then proceed immediately to the hospital for a single radiation to the area.  This has been my most successful treatment for very large keloids.  Although it is impossible to guarantee the the keloid will not reoccur, the combination of surgical excision and single dose radiation has been a very positive treatment in my practice.

Chemical Peel

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  +Vaibhav Shah 

                                               Chemical Peel.

Preparing for your Peel

        When considering a chemical peel, it requires a serious look at the patient’s skin care program (or lack thereof).  A surgeon should never “just peel a patient”.  All patients that are going to have a chemical peel must first pre condition their skin by using prescription skin care products.  Retin A and a bleaching agent like hydroquinone are the bare minimum treatment that must be done several weeks before a chemical peel.  By using these creams, the skin is conditioned to allow the acid to better penetrate and the healing is also easier.  In addition, the post peel complications are also reduced by pre conditioning the skin a month before the peel.  Getting your face peeled is like getting your car painted and just as you must take care of the new car finish, the patient must also care for their new skin.  In reality, all patients should be on a “lifetime skin care” program and beginning this before the peel is a great place to start.  Then, after the peel, these creams are continued as every day skin care, hopefully forever.  There is scientific basis that these products, in prescription strength, can reverse many aging changes as well as reduce future problems.  This type of skin care is really simple and cost effective and takes about as long as brushing ones teeth, so there is really no excuse not to embrace this concept.

         The darker the skin type, the more potential problems there are with skin resurfacing.  Pigmented skin can be unpredictable in terms of peeling and healing.  Skin of color can be much more reactive to post peel pigmentation changes and by using the prescription creams, many of these problems can be reduced or eliminated.  If a patient does not have enough discipline to use prescription skin care products before and after their peel then they should not have a peel as they are missing the ability to make a true difference in their final result.

Types of Peels

      There are many types and levels of chemical peels varying from ultra light to deep peels.  The lighter the peel, the less the recovery and result.  Again, the result from a chemical peel is directly related to the depth of the skin damage.  Lighter peels are tolerable without anesthesia because the acid is weaker and the damage is less.  This means that the patient will not see very much change in pigment and wrinkles.  If a patient has many light peels over a period of time, they may see a change but a patient who expects much from a light peel will be disappointed.

     The medium depth peels are the most popular because the deliver a bigger “bang for the buck”.  These peels generally require anesthesia (at least in my practice as I disdain suffering) and the recovery is about one week.  Patients undergoing a medium depth peel can expect really noticeable and lasting improvement in their pigment related problems.  Most age spots, liver spots and sun spots (all slang for the medical term “lentigos”) and freckles are generally improved or eliminated with medium depth peeling.  In addition, fine lines and wrinkles (like the type on the lower eyelids) are generally improved.  The medium depth peel will also improve skin tightness and smoothness and in some cases reduce pore size.  This type of peel is like stripping coats of wallpaper or paint or power washing your deck.  It literally gets rid of the aging changes of the outer skin layers.  Finally, the entire chemical peel process causes the deeper skin layers to produce new collagen which is the building block of youthful skin firmness and tightness.

     Even with medium depth peels, the skin damage may not be totally corrected and the patient may require additional peels.  I have some patients that do a medium depth peel every 3-4 years and I have some patients that do them twice a year.  It all depends upon the amount of skin damage and the patient’s desired result.

      There are also very aggressive chemical peels know as “deep chemical peel”.  This type of peeling is more dangerous and has many more complications and has largely fallen out of use by most practitioners, largely due to the availability of laser technology.

Before your Peel

      The remainder of this blog will deal with medium depth chemical peeling.  Since the skin is damaged to a deeper level with the medium depth peel, several medications are used before and during the recovery.  An antiviral drug is used to prevent herpes outbreak and an antibiotic is used to prevent a bacterial infection of the healing skin.  These are frequently started 1-2 days before the peel and taken for about a week.

During the Peel

     In my office, the patient arrives the morning of the peel with nothing to eat or drink eight hours before surgery.  They are photographed with digital photography and ultraviolet photography (which shows the pigment better) and an IV is started with sedation administered.  The face is then cleansed with acetone to remove the skin oils and the peeling acid solution is applied.  The patient does not feel the discomfort due to the sedation but if they were awake, it would be intolerable.  Several coats of the acid are applied depending upon the patient’s skin type, color and degree of damage.  As the peeling acid is applied the skin takes on a white appearance (referred to as a frost) which indicates the degree of damage to the outer skin layers.  The procedure is stopped when the appropriate level of penetration is achieved.  At this point, the face is coated with Vaseline and the anesthesia discontinued.  When the patient awakes, they will feel the sensation of asunburn, but it is not an intolerable feeling.

After the Peel

         For most patients, the first few days after the peel are very uneventful.  Their skin will become somewhat darker looking and there is tightness but not usually any significant discomfort.  Once in a while, some patients will experience significant swelling, especially around the eyes and cheeks, but this is an exception instead of a rule.

        Post peel care involves  washing the face with a gentle cleanser such as Cetaphil and patting the face dry with a towel.  Vaseline is applied continually, around the clock, until the peeling is finished.  At this point a gentle moisturizer is then applied.

          About the third to the fifth day after the procedure the dead skin will begin to split and peel.  This will occur first in the areas of increased movement such as around the mouth or the Crow’s Feet regions.  The rest of the face (and or neck) will also begin to peel and it is important for the patient not to pick at the peeling skin (although it is tempting) as it can leave scars on the face.  Generally, all the peeling is complete by one week and the patient is back in makeup if desired.  This relatively short recovery makes peeling an attractive option.  If it weren’t for the fact that the patient has skin peeling from their face, they could go to work as there is usually no pain or problems, they just look scary!  Patients that work from home or don’t care that their co-workers know they had a peel may not miss any work.  I personally had a medium depth peel and went to work every day of the process.  It was actually helpful to show patients what they would also look like with the same procedure

          It is important to protect the new skin with sun block and to continue gentle washing and application of a neutral moisturizer.  Several weeks after the peel it is important to get back on the prescription creams to maintain the new result and reduce future damage.  Most patients are more serious about skin care after the peel as they desire to “protect their investment”.

Dysport V/s Botox

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 +Vaibhav Shah 

 +Vaibhav Shah 

                                                    Dysport  V/s Botox

      As neurotoxin science continues to advance and more drugs become available, patients will be offered more choices of treatments.  Currently Botox (Allergan) and Dysport (Medicis) are the only FDA approved neurotoxins (also called neuromodulators) to treat facial lines and wrinkles.  Numerous other similar drugs are currently in the pipeline for FDA approval, including products from China and Germany.  Patients outside the USA have more options and US patients will soon have some of these options.  More options are not necessarily better options as Botox and Dysport have long track records of safety and efficacy, but these new products will more than likely also offer safety and effectiveness and may also be more cost effective for patients.

     All neurotoxins will be compared to Botox in terms of safety, efficacy, time of onset and duration of the effects.  As with any new product competitor on the market, positive and negative rumors will abound that can assist or detract from the new product.  Finally, all new products will settle in to their niche based solely on their effect and not conjecture.

     Dysport has big shoes to fill in taking on Allergan’s previous monopoly of Botox.  Dysport has an excellent track record in Europe where it has been an option for a decade.  Like any new drug, doctors must figure out “the right way to use it”.  More than ever before, drug companies are strapped in getting the word out by Big Pharma regulations.  Although regulation is necessary, drug companies are literally hamstrung and sometimes voiceless.  Dysport would love to tell doctors the “best way” to use the new drug, but simply are not allowed, so it rests in rumor and conjecture as the means of determining “best practices”.

    The biggest question of doctors new to Dysport is “how does the Dysport dosage relate to Botox dosage.  Initially, doctors were saying that “one Botox unit should equal 2.5 Dysport units”.  Although not an official comparison, this suggested that in order to have an equal effect, a patient that would normally have 20 units of Botox to treat their frown lines would require 50 units of Dysport to appreciate the same effect.  Comparison of units are not “apples to apples” official pharmicopia, but rather convenient conversions to anecdotally arrive at a standard between the two drugs.  Unfortunately, I believe that this first round of “units to units” comparison gave Dysport the short end of the stick.  Here is the reason.  When a new drug is introduced that competes with a standing giant, patients will try it (or not try it) based on numerous factors.  These selection factors include the advice of the treating doctor, cost factors, rumored advantages, the “newness” factor and the possibility that the new drug will simply work different or better.  Herein lies the catch.  If a patient has been getting successful Botox treatments with 20 units to their frown lines and wants to try the new Dysport and their doctor gives the rumored 2.5:1 ratio (50 units of Dysport), the patient is going to be a hard line test of which one works best.  In my experience, the 2.5 conversion is not enough Dysport to produce the effect of 20 Botox units.  If so, the patient will have a less profound or shorter acting effect and Dysport will be “dissed”.  My experience (and that of other surgeons) of using 3 Dysport units for 1 Botox unit seems to be a more accurate dosage in the quest for equipotent treatment between the two drugs.  If doctors are truly interested comparing these two drugs, they must use an equipotent dosage, which I believe to be 3 Dysport units for each Botox units or 60 units of Dysport for an area usually treated with 20 units of Botox.  Failure to use this ratio may give patients a false comparison of the effects and longevity of Dysport.

Why is all of this important? 

         Personally, I feel that Allergan and Medicis are both great companies and I use fillers and neurotoxins from both of them.  From a doctor standpoint, you have to offer all contemporary options to your patients and from a consumer standpoint, every Coke needs a Pepsi.  What is important is that when comparing on new product to another, it is done in a fair way for the surgeon and patient to accurately evaluate.  Having said this, I believe the fair and balanced (hey, does that sound familiar?) way to this is to inject 3 Dysport units for where you would use 1 Botox unit.  Then the surgeon and patient can fairly evaluate the drugs.  It is unfair for the company and patients to compare with a lesser amount.  You will never find an official chart that says use 3:1 and Medicis is not allowed to even think that out loud, so it is up to the experience of scientifically minded clinicians to fairly sort this out for everyone else.  I am trying to do my part and I think it is 3:1 ad nauseum. To prepare Dysport for this dilution, 3 cc of preserved saline is added to the 300 unit Dysport vial.  Five  syringes are drawn up and each will contain 0.6 cc or 60 units.

Jaw Surgery Treatment

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 +Vaibhav Shah 

                                               Jaw Surgery Treatment

         Orthognathic treatment takes about two years to complete. It is very specific and consists of several stages, one being orthognathic surgery. Once begun, it is seldom possible to reverse the orthognathic treatment or switch to non-surgical treatment, so it is strongly recommended that the original treatment plan be completed once begun. A patient who has decided to have an orthognathic treatment should understand that this surgery is a complex and time consuming process. Therefore, only a combination of the patient's cooperation and good-will, accompanied by the doctor's support, can meet the challenge of achieving correct occlusion and facial harmony.

The course of treatment

        The treatment plan is prepared after the initial consultation. The treatment plan is a detailed explanation of the entire treatment process for each individual patient which then, every doctor involved in the treatment will follow. It is of vital importance that the patient makes a resolute decision about having orthognathic treatment, for once started, the treatment is extremely difficult to reverse.

        At the beginning of the treatment, teeth are restored while, at the same time, useless teeth, as well as, the wisdom teeth are removed. Subsequently, once the orthodontic treatment is started it lasts for about 18 to 24 months. When the teeth are set, orthognathic surgery is performed on one or both jaws, followed then by the final orthodontic treatment which, in itself, lasts approximately 6 months.

       Once the braces are removed, if necessary, select teeth may receive restorations or crowns, or, dental implants may be inserted and restored in edentulou areas. After all this is completed, the patient will enjoy and benefit from a stunning smile and pleasing facial features.

FAQ on Hair Transplant Surgery

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  +Vaibhav Shah 

                       Frequently Asked Questions on Hair Transplant

*Hair loss in women – can females do hair transplantation?

       The short answer is yes; as long as the women’s hair loss is concentrated in defined areas like in the classic male pattern baldness (i.e. the woman’s hair loss is not too diffuse or thin throughout their entire scalp).

       Consider what Dr. Dow Stough, hair transplant surgeon in Texas writes about women hair loss – “Hair loss in women is culturally unacceptable despite the fact that up to 40% of the female population experiences some hair loss in their lifetime. It is not uncommon, but the stigma attached to female baldness is an extremely stressful and unwelcome event. In fact, androgenic alopecia in women can be psychologically debilitating. There have been several medical studies which have concluded that although alopecia is clearly a distressing experience for both sexes; its effect is much more problematic in women. Most women go to extremes to conceal and treat their hair loss; they use a broad array of creative camouflaging and hair thickening cosmetic techniques in an attempt to mask the condition.

     Women who are experiencing hair loss should undergo a thorough investigation by a dermatologist. The medical workup and testing for women with hair loss is very involved and time consuming. The most difficult cases, are women with diffuse hair loss, i.e. balding which is not concentrated in the frontal regions of the scalp.

     In cases of non-patterned alopecia, a dermatologist will usually recommend laboratory tests, which may include a complete blood count, iron levels and thyroid studies. An extensive medical drug history and family hair loss history must also be obtained, and in some cases testing for a hormonal imbalance is warranted.

      For those women who do not have diffuse alopecia, the diagnosis is simplified and much more direct. These women are classified by the Ludwig classification system. There are three categories; Ludwig I, Ludwig II, and Ludwig III. Those with a Ludwig I pattern are not candidates for any surgical treatment. They are best treated with topical treatments. Patients with more advanced hair loss, those who are classified as Ludwig II or Ludwig III categories, are possible candidates for hair transplantation. They are acceptable candidates if they have an adequate amount of donor density. The donor area is the hair found in the back of the scalp.

    In those women who have complete balding in the central and frontal of the scalp, hair transplants are a viable option. The results from this transplantation can be truly outstanding since many women retain the frontal hairline and it does not need to be recreated.

       Hair transplantation in women with hair loss caused by cosmetic surgery also yields excellent results. By camouflaging the scars resulting from brow lifts or face lifts these patients are able to achieve their expectations”.

*Can I wear a hairpiece until growth of the hair transplant is complete?

      Hair pieces can be worn between surgical visits if you want, as long as proper hygiene and ventilation of the scalp are maintained. For the first 7 to 10 days, post hair transplant, you have to be extra careful not to disturb the transplanted grafts while putting on or off the hair piece.

     After that, in case your hair system requires use of adhesive, we advise you to take care that the adhesive/tape does not rest over the transplanted area.

*Since Finasteride (Propecia/Finpecia) is now available, will hair transplantation be a thing of the past?

     While Propecia (Finasteride) and Rogaine (Minoxidil) have been proven to regrow hair, in a percentage of patients, they will not grow all your hair back. Both products have not been proven to grow any significant hair in the frontal and temple areas, which are the main areas of concern for most people. Their greatest benefit seems to be in slowing down the hair loss process.

*What about “Scalp Expansion and Reductions”?

      Scalp reductions were first introduced in the mid-1970’s as a way of treating an individual with a midline bald spot. Although several design approaches can be used, an elliptical approach is generally the most common. Prior to the excision, a surgical balloon may be inserted below the scalp and filled gradually with liquid to improve the scalp laxity. With this procedure, an ellipse of bald skin is removed centrally in the crown area and the hair-bearing scalp on the sides of the head is stretched toward the middle to obtain closure. Because scalp reductions do not allow for an upward and forward advancement of the entire scalp, they are not effective in treating patients who possess or have the potential for more extensive baldness.

          Due to this inherent surgical limitation, as well as the aesthetic drawbacks, which include an excessive stretching back of the bald area and increased receding at the temples, the scalp reduction procedure is considered outdated for the treatment of moderate to extensive baldness. Newer hair transplantation procedures offer more predictable and better aesthetic results, and often require fewer surgical sessions.

*Does removing hair from the donor area on the back of my head leave a gap?

       The scalp is elastic. When the donor strip of hair is removed, the scalp on both sides is pulled together and sutured. The only evidence of surgery is a suture line hidden under the hair that grows vertically on the back of the head.

*Are there risks involved with hair transplantation?

       Elective surgery to improve physical appearance is universally accepted and is being performed successfully everywhere there are qualified specialists. Hair transplantation procedures differ from general surgery, however, in that they involve only the outer layers of the body. Thus, any risks involved in hair transplant are similar to those with any outpatient surgery. Hair transplant, by itself, has no adverse effect on the brain, eyes, memory etc.

*Is hair transplantation surgery painful?

      The discomfort associated with hair transplantation surgery is usually comparable to that of dental surgery. Pain medication is always offered, though its use is limited generally to the first few days after surgery.

*Will my hair require special care after hair transplantation?

     Your newly restored hair will grow and require the same maintenance as your original head of hair. It’s your hair and can be colored, permanently waved or styled in a variety of ways suitable to your lifestyle. You can even shave them off, they will grow right back.

Before After

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Scalp Conditions and Hair Loss

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 +Vaibhav Shah 

                                Scalp Conditions and ir Loss

          There are several scalp conditions that can cause an itchy scalp, hair loss, and flaking; most can be treated with topical scalp meds. Among the most common is dandruff, which causes dead skin cells to flake and fall from the scalp onto the shoulders. Although it is a nuisance and is unattractive, this condition is primarily cosmetic; it does not result in a dry scalp, hair loss, or other serious consequences, and can generally be treated using dandruff shampoos that contain ketoconazole, zinc pyrithione tar or selenium oxide.

        Other common conditions include excessive oiliness (seborrhea), and oily crusts adhering to inflamed, itchy, moist scalp skin (seborrheic dermatitis, also known as cradle cap in infants). The latter condition tends to be the most severe and should be treated by a dermatologist or other physician. However, an itchy scalp and hair loss rarely go hand-in-hand. However, regular scratching of the scalp can lead to hair breakage.