Plastic Surgery Dictionary will help you with the medical terminology that your doctor might use when explaining a procedure to you. If you have heard Plastic Surgery related terminology used but were unclear of the spelling or could not find the words listed here please feel to e-mail Dr. Stone for an explanation and inclusion in this growing list. Return to this page to learn new words as well as new procedures as they are added. Click on a letter in the box to the left to move to the corresponding letter's section of this page. You can also use the find on this page function on your browser to search for specific words. If you come across a word in a definition that you do not understand click on that word to go to its definition & then click back on your browser to continue reading in the prior definition.
Abdominoplasty-a plastic surgery
procedure designed to tighten the abdominal skin and muscles. Generally
a variable amount of skin is removed below the belly button level and
the skin incision is designed to be hidden within the boundaries of a
bikini or undergarment.According to present day plastic surgery lore there
are 5 types of abdomens
1 - requires no surgical treatment
2 - is best treated with liposuction only
3 - is best treated with a combination of liposuction & a mini abdominoplasty/tummy tuck
4 - is best treated with a combination of liposuction & a modified abdominoplasty/tummy tuck
5 - is best treated with a combination of liposuction & a standard abdominoplasty.
In relatively few cases there is little or no liposuction needed in a specific patient who lies in one of these categories.
Which category you are in depends on the relative amounts of excess skin/fat vs. abdominal muscle laxity you have above vs. below the navel. There are some good plastic surgeons who believe 4 should not exist. Also, there are probably naturalists, trainers, etc. out there who believe none of these should exist except 1. My experience & training lead me to believe that all 5 are valid & that diet & exercise can be combined with any of the 5.
There are a significant number of people out there with a condition know as diastasis recti (separation of the 2 central abdominal muscles) which is never amenable to diet or exercise. It is more common after the inherent stretching of pregnancy especially if the muscle is cut during C-section. These people need surgical tightening of the displaced abdominal muscles. Excess fat can be lost to some degree with diet & exercise depending on age, metabolism, etc.. Resistant fat may be amenable to liposuction. The end result of liposuction in turn is dependent on the ability of the skin left behind to shrink.
Excess skin is more of a problem. Its ability to shrink after liposuction, pregnancy, large weight loss (decrease in the amount of fat under the skin) or decrease in underlying muscle mass is dependent on age, genetic makeup & how much shrinkage is required to get the desired result. If you need a lot of shrinkage, especially if you are older, it just doesn't happen. The result is flabby wrinkled skin that may have stretch marks. These people require surgical removal of the excess skin because once the skin has been stretched beyond a certain limit it will not shrink much like an overstretched rubber band that has lost its elasticity. If you are planning to or are in the process of losing weight, at any age, it is better to go ahead with the weight loss for health reasons. Once the weight is lost you can then continue an exercise program to tone the muscles. If the skin doesn't shrink it can be excised at a later date. There is no form of exercise that can shrink excess skin. Mild excesses, however, may appear less so after increasing the bulk of the underlying muscle.
Sometimes a c-section scar forms a continuous scar between the skin & the deeper muscular structures. The scar contracts as most scars do & the skin deviates towards the abdominal muscles. In some people this creates a layer of fat & skin than can hang over the c-section skin scar. This is removed during abdominoplasty & the various layers of the abdominal wall are realigned.
Abscess(ab'ses)-a circumscribed collection of pus. By definition virtually all abscesses need to be incised and drained as this concentrated collection of large numbers of bacteria is resistant to antibiotics.
Accutane-a Vitamin A related compound that inhibits sebaceous gland function and reformation of the outermost layer of skin. It is used in the treatment of severe acne unresponsive to antibiotics. These glands furnish the cells that repopulate the skin surface after the surface has been denuded. If the depth of denuding is deep enough to affect the depths of these glands the risk of scarring dramatically increases. The quickest healing with least scar formation occurs in areas of the skin surface that have the highest concentration of sebaceous glands i.e. the face. Major cosmetic procedures to the skin surface should be undertaken 12 to 18 months after the last dose of accutane to allow sufficient time for sebaceous gland recovery & avoid bad scarring. Accutane slows the skin surface healing process.
Actinic Keratosis-single or multiple discrete but poorly demarcated
superficial skin lesions. They can be red & most commonly have a gritty
sandpaper like feel on the surface. They are found in chronically sun
exposed areas in over 50% of light skinned individuals over the age of
40. They are an indicator of chronic sun exposure & are premalignant
i.e. are not cancerous but can become skin cancers if left untreated for
a number of years.
The treatment is ablation by freezing with liquid nitrogen, topical 5-FU skin chemotherapy, chemical peel, laser or dermabrasion. Dr. Stone has had one removed from the left cheek with a laser & you can't tell where it was. The best treatment for a specific individual is dependent on the number of actinic keratoses to be ablated & the doctor's experience.
Alloderm-collagen sheets obtained from human organ donors. It consists of the deepest layers of skin and contains no living cells. Therefore, it is not subject to transplant rejection or common infections. It is processed according to U.S. Food and Drug Administration and American Association of Tissue Banks regulations. Placing this collagen under the skin replenishes the missing deeper layers of skin thereby elevating depressed scars or skin wrinkles. It can also be placed in the lips to make them appear larger. The material can last more than 2 years without any visible loss of the collagen but there is no guarantee as to how long the correction due to insertion of this collagen will last. The edges of the sheet can felt but not usually seen for 4 to 6 weeks. After that there is ingrowth into the material & the edges cannot be felt or seen. Dr. Stone currently uses Alloderm for lip enlargement/augmentation, nasolabial fold treatment & frown line treatment.
Alopecia(al'o-pe'shi-ah)-medical term for hair loss.
Alpha Hydroxy Acids-a group of acids with a specific general chemical structure available in various strengths & used in chemical peels. The weaker strengths are found cosmetic products that maintain or rejuvenate skin.
Artecoll-a soft tissue filler that consists of microscopic Plexiglass plastic beads suspended in bovine collagen. When the bovine collagen reabsorbs, the tiny spheres trigger the body to produce its own collagen to envelop them-making it a permanent tissue filler. It has been available in Europe since the late 1980's but as of mid 2001 had not been approved for use in the US by the FDA. It can yield a lumpy appearance which is permanent.
Arthrodesis-the obliteration of a joint between 2 bones & surgical fusion of those bones to prevent motion. This is commonly performed in the hand to cure the incapacitating pain of arthritis or to treat severe traumatic injuries.
Basal Cell Carcinoma-the most common type of skin cancer. It arises
from the basal cells of the outermost layer of skin (epidermis), external
root sheath of hair follicles or from a precursor lesion (sebaceous nevus
of Jadassohn-usually seen on the scalp). They occur most frequently in
areas with the largest concentration of pilosebaceous follicles i.e. the
face. They are locally invasive & only 1 in 1,000 to 1 in 35,000 metastasize
to distant areas of the body. The cancers are more friable than normal
skin & so bleed easily when rubbed.
Factors that increase one's risk for basal cell cancer include sun exposure (it is frequently seen in surfers, outdoor construction workers...), light complexion, radiation therapy to the skin, immunosuppresive therapy after organ transplantation, exposure to arsenic insecticides & a congenital disease called xeroderma pigmentosum. Cells damaged by sun exposure may take 20 or more years to visibly manifest themselves as basal cell cancers. Thus, it can be hard to distinguish between a new & a recurrent basal cell cancer.
There are 4 clinical types (nodulo-ulcerative, superficial, sclerosing/morpheaform & cicatricial) based on their appearance. However, the treatment is the same for all- currettage(scraping), topical 5-FU cream, surgical excision or radiation therapy(for older patients with cancers in areas that cannot be excised). Proper care results in greater than 95% cure rates. Recurrent cancers are more aggressive & harder to cure. The recurrence rate is dependent on the entire removal of the cancer (proven by microscopic examination of the excised specimen) rather than the clinical type. However, once you have had one you are obviously at greater risk of getting another anywhere you have skin than someone who has never had basal cell carcinoma. They are only predictive of future basal cell carcinomas or squamous cell carcinomas of the skin. They are not predictors of any other type of cancer. It is important that you wear strong sun screen anywhere you have had these skin cancers & all areas exposed to the sun.
Blepharoplasty-plastic surgery of the eyelid usually involving removal of excess eyelid skin. This can be cosmetic or reconstructive in nature.
Blepharoptosis(blef'ar-op'to-sis)-drooping of the upper eyelid. In normal forward gaze the edge of the upper eyelid should cover just the upper 2mm of the iris (colored part of the eye surrounding the pupil). If it lies lower than this blepharoptosis exists & can be corrected by a variety of procedures depending on the specific cause of the problem & which remaining muscles are functional.
Board Certified-Board certification in & of itself has nothing
to do with being up todate or continuing medical education. In order to
qualify as a board that can award certificates a group (Board of Dermatology,
Surgery,Neurosurgery, etc.) must be listed with the American Board of
Medical Specialities(ABMS). There are no recognized boards of specific
procedures (such as liposuction or hairgrafting, etc.). Certificates of
added qualification are awarded by some boards to those physicians who
have additional fellowship training in subspecialty areas such as Hand
Surgery. In order for new boards or certificates of added qualification
to be allowed in the system members of ABMS must vote on the matter.
The requirements or prerequisites for board examination vary from board to board. They include number of years of training, number & type of procedures performed, etc.. Some require passing a written examination before undertaking an oral examination. Some only require a written examination. Others require passage of a certain amount of time before examinations can be taken. Board Certificates, i.e. board certification, are given after the examinations are passed. Depending on the board recertification exams (usually written) are required every ten years or so. Although passage of board examinations are a form of continuing medical education (CME) one does not require CME credits to take the exam.CME credits are also awarded for attending physician educational symposia, writing scientific papers, lecturing, etc.. In order to maintain a medical license in any given state or membership in a medical or specialty society a certain number of CME credits are required per year. One must have a valid medical license in order to sit for a board examination.Thus, the mere presence or absence of board certification does not equate with the abilities of a given physician. It depends on whether or not they took the exam, if they failed or passed, if they do not qualify to take the exam, if they have been in practice a sufficient length of time to take the exam, etc..
By using the word "board" on a certificate that is not recognized by the American Board of Medical Specialties the consumer is confused as to what board certified means. You cannot have a board in one procedure & you cannot have a board without a residency training program. Why don't we give out board certificates in liposuction, appendectomies, etc.? The reason is obvious. To make up for this the ABMS has allowed actual boards to give out certificates of added qualifications. These certificates are overseen by one or more boards. For example the certificate of added qualifications in hand surgery are overseen by the boards of Plastic, General & Orthopedic Surgery. This process favors consumer safety over the benefit of any individual or group. In the state of California doctors can be sactioned for stating they are board certified in a specialty when they are not or if they advertise certification in unrecognized boards.
Body Contouring-is the group of plastic surgery procedures used to change body contours. It includes abdominoplasty or tummy tuck, brachioplasty, liposuction, thigh buttock lifts, brachioplasty, reduction mammoplasty or breast reduction & mastopexy or breast lift.
Botox-Botox or botulism toxin
is a compound produced by bacteria-not the bacteria themselves. Therefore
it is not contagious or infectious. It temporarily paralyzes muscle beginning
about 1 week after being injected into the muscle. Although the results
can be dramatic they are short lived-usually around 3 months. Repeat injections
are therefore required. There is some talk that individuals may build
up resistance to the compound over time. There is no documentation of
permanent injury to the muscle. Lastly, there are 3 forces creating facial
wrinkles although some wrinkles may have more than 1 contributory force
to varying degrees:
1aging & sun exposure of the skin - cheek skin wrinkles in the elderly
2chronic muscle action - crow's feet & vertical wrinkles between the 2 eyebrows
3weakened supporting tissues with age & the constant forces of gravity-the jowl wrinkles on either side of the chin
Botox only works on the muscle contribution to wrinkle formation & the more muscle action contributes to a wrinkle the more effect Botox will have, temporarily. Additionally, if a crease cannot be effaced by spreading the skin with the fingertips Botox will not erase the crease because the problem is at the skin level which is not directly affected by the Botox.
Boutonniere Deformity(boo-ton-yair')-is present when the middle joint of a finger, the first joint after the knuckle, is held in a flexed position even when the fingers are actively extended. If severe the joint cannot be straightened even when the finger is manipulated by the opposite hand. It is commonly seen with scarring of the flexor tendons or destruction of the extensor tendons by arthritis. The treatment is dependent on the cause of the problem & its severity.
Brachioplasty-plastic surgery performed on the upper arm to improve contours. It involves removal of skin on the inner aspect of the upper arm to tighten it & usually involves liposuction to the area as well.
Breast Lift-see Mastopexy
Browlift-plastic surgery performed to raise
the brow. Facial muscles affecting the eyebrows can be classified as those
that pull the eyebrows toward the midline & downward (corrugator &
orbicularis muscles) & those that raise the eyebrows upward (frontalis
muscle). These muscles work in an agonist/antagonist fashion much in the
same way as flexor & extensor muscles affect wrist, hand & finger
motion. The downward/inward muscle action is focused on a narrow area
while the elevating frontalis muscle works over a broader area-between
the outer edges of both eyebrows. Thus over time the downward/inward muscles
win, the eyebrow hairline moves southward & a permanent vertical skin
crease is created above the nose between the eyebrows. Although the frontalis
loses over time its overactivity results in the formation of horizontal
forehead skin creases.
After a long period of time these creases become very deep. Scar tissue can even form between the undersurface of the skin & the muscle or bone. When the creases are milder they readily respond to botox injections which temporarily paralyze the muscles that create these creases/wrinkles. For more severe prolonged cases excess forehead skin is created by this process that complicates the treatment. For permanent treatment of the problem the inward/downward muscles are removed via endoscopic forehead lifts, eyelid/blepharoplasty incisions, regular open forehead lift (an incision from ear to ear over the top of the head) or even through nasal incisions during rhinoplasty/nose jobs. If there is a large excess of forehead skin this has to be removed by open forehead lift surgery. Removal of the muscles does not result in much functional deficit because these muscles are only activated when exposed to bright light or sunlight, when straining the eyes to compensate for poor eyesight or when the eyes are exposed to noxious stimuli such as smoke.
In the early stages treatment can include botox to temporarily paralyze muscles, alpha hydroxy acid creams or laser treatments to lighten creases, being fit for proper eyeglasses or contacts to prevent squinting, stop smoking (the noxious fumes cause reflex squinting), regular use of sunglasses to prevent squinting while exposed to bright sunlight...
The classical open forehead lift surgery or coronal browlift involves placing a incision from ear to ear over the top of the head. Loss of hair in the scar line &/or hair thinning in front of the scar line are the most common complications. To prevent a visible scar the incision should be placed about 3 inches behind the hairline & the incision bevelled to prevent damage to hair follicles that normally are situated at a less than 90 degree angle to the skin surface. The only way to treat this complication is hairgrafting because if you just cut out the area lacking hair the new scar line will stretch & thicken becoming even more visible.
The endoscopic approach was introduced to prevent this complication by placing 3 to 5 less than a half inch incisions near the hairline & introducing endoscopic equipment through these incisions to perform the procedure. This technique though is not without it's own possible complications which include loss of hair at the access incisions & incomplete removal of the corrugator muscles (the muscles that create frown lines between the eyebrows & that are removed in browlift/foreheadplasty procedures). In the past most physicians also placed some sort of fixation (a screw or suture) to keep the brow elevated during the initial healing period.If you have a lot of excess forehead skin especially after the age of 50 or 60 it just will not shrink after the endoscopic approach so you need to have the open approach procedure. Thus the endoscopic approach is probably best for those with milder aging changes of the forehead.
The issue of too high a forehead is separate & not necessarily due to which specific technique was used. In a middle aged or older adult the forehead height also know as upper face height should be 1 to 2cm more than the midface height (the distance
between the eyebrow level & the level where the nose meets the upper lip). If browlifting is over done the eyebrow can be raised too high giving a constant startled look. In a women the eyebrow should lie about 5mm above the upper boney rim of the eye socket. You could place grafts in front of the frontal hairline if too much scalp has been removed by the open procedure but this would not address the high eyebrows which presumably would be present. Recently procedures have been developed to raise the brows without raising the frontal hairline for people who already have high foreheads.
Dr. Stone has performed all 3 procedures endoscopic, coronal & removal via eyelid blepharoplasty incisions. Clearly all of these methods are valid but different patients are better candidates for one approach vs. the others. He no longer uses screw or suture fixation in endoscopic brow surgery as they seemed to be more trouble than they were worth.
Buccal (buk'ahl)Fat Pad-fat that lies deeper within the
cheek than the more superficial fat just under the skin. The pad in some
people reaches up to the temple area by extending upward under the arch
of the cheek bone. If there is an overabundance of fat in the pad ones
face may appear round. Over doing removal of the fat pad to achieve a
waif look can make one look cadeveric if there is significant shrinkage
of cheek fat with aging. For the very round face removal of the buccal
fat pad should be combined with liposuction of some of the superficial
fat in order to make a significant difference in the shape of the face.
Burn-injury to the skin caused by flame, heat liquid or solid, chemicals or abrasive surfaces (road burn). The depth of injury is referred to as first, second or third degree. Chemical peels, laser treatments & dermabrasion are controlled forms of first or second degree burns.
Canthoplasty-Canthopexy-Canthus (kan'thus) refers to the inner & outer corners of the eye where the upper & lower eyelids meet. In cosmetic surgery canthoplasty involves placing a suture between the outside internal edge of the lower eyelid (canthal ligament) & the outside rim of bone surrounding the eyeball. This tightens the lower eyelid which becomes lax as part of the aging process. It is commonly performed together with cosmetic surgery of the lower eyelids & midfacelifts. When the laxity is very severe the ligament is divided & some portion of the lower eyelid is removed before placing the suture, a canthopexy.
Capsule-When a breast implant is placed the body attempts to wall
it off forming a capsule around the implant. This capsule can be present
within a week after surgery & is eventually present in all breasts
containing implants. The end result look of a breast containing implants
is due to
the implant itself
the patient's breast tissue-skin,gland,fat,chest wall muscle
the capsule formed around the implant.
The capsule can be of variable thickness & have different properties from patient to patient & even right breast vs. left breast. Thicker capsules can contract mishaping the breast & in some cases also cause pain. It is not known exactly why some capsules become more problematic cosmetically speaking than others. It is thought that blood around the implant at the time of surgery or low grade infection early or late after surgery is the culprit. Some capsules cause problems early after surgery & some take years to transform into a problematic capsule. It's not known whether all capsules eventually become problematic but this is a distinct possibility. In the mid 1980s texturing was added to implant surfaces in an attempt to decrease the incidence of capsular contracture. Some surgeons now use only textured implants & others use only smooth surfaced implants saying one is better than the other for cosmetic or other reasons. At least in animal experiments texturing decreases the contracture rates.
When reoperating on a breast with implants in place the preoperative situation & goals of the surgery should be kept in mind. If the patient just wants the implants out it's important to remove as much as the capsule as possible unless the capsule is gossamer thin. If the implant is removed & the capsule left behind virtually intact various problems can occur:
the capsule can contract down into a small sphere since there is no longer an implant to maintain its size - this would crenate (notched or shriveled in appearance) the breast
the capsular surface in some cases can secrete fluid similar to serum or joint fluid which would require drainage
Having said all that it is probably impossible to remove every single cell & non-cellular part of a capsule. Firstly because that's just the way the human eye & hand work-we can't see microscopically. Secondly because especially in very thin individuals it may be dangerous to scrape the back of the capsule off the chest wall. No one wants to enter the chest cavity especially if gel from a ruptured gel implant is present. The problems of crenation & fluid production should be adequately treated by removing the vast majority of the capsule.
There are no external balms, medications etc. that effectively treat capsular problems. The capsule needs to be surgically removed & all consent forms for breast implant surgery should discuss the existence of/possible problems with capsules. Interestingly, of all the non-plastic surgeons out there performing breast augmentation I've never heard of one of them willing to perform breast reconstruction or treat capsular problems.
Capsulectomy-surgical removal of the breast implant capsule.
Carpal Tunnel-The carpal tunnel is
a passageway through the wrist carrying tendons and one of the hand's
major nerves. Pressure may build up within the tunnel
because of disease (such as rheumatoid arthritis), injury, fluid retention during pregnancy, overuse, or repetitive motions. Diabetes, alcoholism, hypothyroidism, and obesity are also all factors predisposing towards developing carpal tunnel syndrome. The resulting pressure on the nerve within the tunnel causes a tingling sensation in the hand especially the thumb, index and middle fingers, often accompanied by numbness, aching, and impaired hand function. This is known as carpal tunnel syndrome.
In some cases, splinting of the hand and anti-inflammatory medications will relieve the problem. If this doesn't work, however, surgery may be required.
In the operation, the surgeon makes an incision from the middle of the palm to the wrist. He or she will then cut the tissue that's pressing on the nerve, in order to release the pressure. A large dressing and splint are used after surgery to restrict motion and promote healing. The scar will gradually fade and become barely visible.
The results of the surgery will depend in part on how long the condition has existed and how much damage has been done to the nerve. For that reason, it's a good idea to see a doctor early if you think you may have carpal tunnel syndrome.
The "classic" surgery for carpal tunnel syndrome involves an open technique where a small incision is made over the region of the ligament which compresses the median nerve. This ligament is released to decompress the median nerve. With the introduction of endoscopic surgery in other locations in the body, some hand surgeons are using a similar technique at the wrist. Usually two small incisions would be substituted for one larger incision at the wrist level. The incidence of nerve injury is slightly higher with the endoscopic surgery, but the return to work time may be slightly earlier. Because of the slight increased risk to the median and ulnar nerves associated with endoscopic carpal tunnel surgery, the majority of surgeons prefer an open technique. It is recommended that you discuss in detail these two types of surgery with the particular surgeon you have chosen to do your surgery. Also see Nerve Compression.
Cartilage(kar'ti-lij)-a tissue characterized by its low blood supply, ability to maintain shape & small number of cells dispersed in a matrix of material produced by those cells. There are different types of cartilage that have different properties such as flexibility. Cartilage forms the central layer of the ear, the tip of the nose & the common wall between the nasal airways. This type allows the ear & nose to maintain their shape & yet remain flexible. A nonflexible cartilage covers the ends of bones on joint surfaces & allows smooth non-painful range of motion.
Cellulite-the only word we have to describe the uneven pitted
surface or dimpling of the skin commonly seen on the thighs of women.
I am not sure who first coined the term but doubt it was first used by
cosmetics manufacturers to describe this condition. It is common in women,
rarely seen in men & begins at various ages depending on body habitus,
genetic makeup, etc..
The outer skin is separated from the underlying muscle by a layer of fat. The fat has little strength therefore lying parallel to the skin throughout the fat layer is a sheet of connective tissue called superficial fascia. This fascia in turn is connected via finger like septal extensions through the fat to the overlying skin & underlying muscle. This architecture helps hold the fat together & keep the skin from falling down like a loose sock. In some areas the distance between skin, superficial fascia & muscle is very small. In men the superficial fascia is much thicker than it is in women & the septal extensions are crosshatched lying oblique to the plane of the skin. In women the septal extensions are fewer & lie perpendicular to the skin surface. In some areas the distance between skin, superficial fascia & muscle is very small. In men the superficial fascia is much thicker than it is in women & the septal extensions are crosshatched lying oblique to the plane of the skin. In women the septal extensions are fewer & lie perpendicular to the skin surface. Aging, smoking, dramatic weight changes (gain & loss) & the presence of an inherently weaker superficial fascia in women increase the possibility of thigh buttock skin sagging. The muscle layer can be toned up & the fat layer diminished by exercise & dieting but the fascial system once damaged cannot be rejuvenated. The skin also usually is incapable of shrinking once the fascial system is damaged. If cellulite were solely due to the amount of fat present under the skin then men & women with the equal amounts of thigh fat would show similar degrees of cellulite. This is clearly not the case. Even very obese men rarely have cellulite but cellulite can even be seen in slender women with good muscle tone who exercise regularly. Conversely dieting &/or exercise cannot completely erase any signs cellulite.
There are 3 possible causes for cellulite
1)edema or swelling of the skin & fat due to increased water content
2)contraction of the muscle pulling the septal extensions or shortening of these septa resulting in pitting of the overlying skin
3)descent of the skin & fat envelope that normally occurs with aging resulting in skin pitting due to the pull of septa whose length is unchanged. This is more common in women who have an inherently weaker fascial support system to hold the skin up. This problem is aggravated by smoking & dramatic changes in weight (gain & loss).
There are also 3 levels of cellulite severity
1)the skin has to be pinched in order to see surface dimpling
2)cellulite is only visible when standing
3)cellulite is visible when standing or sitting
Treatment of the first cause is straightforward - get rid of the water. The second cause is treated by surgical transection of the responsible septa. The third cause is most common & requires lifting of the skin & fat envelope i.e. a thigh buttock lift in severe cases. There is no difference in fat metabolism in areas of cellulite vs. areas without cellulite. Thus, aminophylline & other creams have no effect. Exercise will have little or no effect because it works on the underlying muscle, not the fascial support system. Fat removal by liposuction or weight loss can diminish the severity of cellulite skin dimpling but will not ameliorate the underlying fascial structural problem that creates it. It will not cure the problem. Unless there is very severe sagging I usually do not recommend a thigh buttock lift in younger women. Endermologie whereby external suction & motorized massage are applied has been certified by the FDA for the temporary reduction in the appearance of cellulite. This may be due to the swelling induced by twice weekly treatments & then the requirement of maintenance treatments. There has been no evidence to date whether or not after a certain number of treatments you can stop & will have permanent reduction of cellulite. For less severe forms of cellulite endermologie may turn out to be the treatment of choice. In severe cases the only solution to the problem is a thigh buttock lift.
Chalazion(kal-a'zi-on)-inflammatory granulomas of eyelid glands (cysts created from plugged glands) that are treated by excision under local anesthesia. They appear as small round pea like masses beneath the eyelid skin.
Chemical Peel-placement of a chemical exfoliative on the skin surface to treat facial wrinkles, abnormal skin growths or abnormal skin pigmentation. The chemicals used are acids such as phenol, salicylic acid, alpha hydroxy acids,... Some acids are inherently stronger than others & some come in a variety of concentrations (from 10% to 50% or more). All destroy the outermost layer of skin with deeper destruction (peel depth) dependent on type of acid, its concentration & the amount of time allowed before the acid is neutralized. As with lasers & other treatments that damage the outer skin layer alterations in skin pigmentation can arise (especially in darker skinned individuals) or scarring. For the deeper peels the recovery time is about the same as for laser-10 to 21 days before make up can be worn. Some sedation/anesthesia is required for deeper peels. Very superficial peeling solutions are present in some currently available over the counter cosmetics. These require consistent use over prolonged periods of time in order to have any visible effect. They also have virtually no down time with virtually no chance of complications thus they can be used without physician supervision. The visible effect however is much less than can be attained with a deeper peel. Deeper peels should only be performed by qualified physicians as the deeper the peel the greater the potential for scarring & pigmentation changes.
Cleft Lip/Palate-refers to clefting of the lip (harelip)&/or the palate. The clefting can be part of a syndrome or isolated in nature. If syndromic the other defects making up the syndrome are investigated so that other problems can be addressed early on. The clefts are surgically repaired usually in the first year of life so that normal speech patterns can be developed by the early second year of life. Once speech patterns have developed it can be bery difficult to alter them. Despite surgical repair residual speech & swallowing problems may persist & may not completely respond to therapy.
Collagen(kol'la-jen)-major protein of connective
tissue, bone, cartilage, skin, tendons, scar tissue... It is not dissolvable
in water. Different types of collagen exist in these different tissues
& in different animals. When a wound or incision heals collagen fibers
are created by cells near the wound & these fibers are crosslinked
or weaved. This strengthens the sealing of the wound so the edges do not
come apart. Thus if collagen production is insufficient wounds do not
heal. If it is over exuberant unsightly scars such as keloids
can be formed.
Injectable collagen is derived from cow skin. It is commonly injected under the skin surface to lighten or erase facial wrinkles or acne scars or make the vermillion border more prominent. Prior to injection a diluted test dose is injected, usually in the forearm, to ensure that no allergic reaction will occur. The test area is examined at 72 hours & four weeks looking for signs of redness, swelling or skin damage. The actual injection can then take place, 4 weeks after the initial test. The material is slowly degraded so that the results of injection last at most 3 to 6 months. Regular injections are required to maintain the results.
Columella(kol'u-mel'lah)-the vertical bridge of skin between the nostrils. On side view the aesthetic position of the skin edge of the columella should be 4mm below the outer rim of the nostril.
Contracture-the effect seen of scar tissue contracting upon itself. After a burn there can be burn scar contracture for example preventing extension or flexion of the fingers. After placement of breast implants the capsule can contract around & squeeze the implant into a tight, hard, round mass. Hence the name capsular contracture.
Cosmetic Surgery-surgery performed to enhance normal structures of the body to make them look better or different. These procedures are not commonly covered by health insurance.
Craniosynostosis(kra'ni-o-sin'os-to'sis)-premature sealing of the spaces between the plates of bone making up the skull under the hair bearing scalp. This can lead to very misshapen heads as a child grows older. The treatment is surgical correction by a team of Neurosurgeons & Plastic Surgeons within the first 1 or 2 years of life.Crow's Feet-refers to the facial wrinkles of aging that form at the outer corners of the eyes & extend towards the temples. The cause of these wrinkles is constant action of the circular muscle surrounding the eye & forehead-temple descent. With aging & gravity the outer forehead & temple skin droop contributing to the appearance of crow's feet. If mild they can be temporarily eradicated by Botox injections. Browlift/Midfacelift give a more permanent result & are more effective on severe crow's feet than Botox.
Cubital Tunnel-Sensation to the little finger is supplied by the ulnar nerve which runs from spinal column along the inside of the arm to the little finger. In the region of the elbow it travels in a tunnel close to the surface. This tunnel is called the cubital tunnel. When one accidentally hits the elbow & feels tingling in the fingers commonly known as striking ones funny bone it is because the nerve in this tunnel has been hit. When the elbow is extended straight out the tunnel is at it's maximum diameter. As the elbow is flexed the tunnel is narrowed & the nerve squashed to some degree. Many people sleep with their elbows flexed possibly due to this being part of the fetal position assumed in utero. Cubital tunnel syndrome is the name given to symptoms that occur from chronic compression of the nerve in the cubital tunnel-numbness of the ring & small finger, wasting away of muscles in the hand & weakened grip strength. If left to progress irreparable nerve damage can occur. In some cases all that is required is the wearing of an elbow splint to prevent flexion while sleeping. More severe cases require surgical decompression of the tunnel. Also see Nerve Compression.
Cutaneous Horn-a usually benign outgrowth of skin in a horn like fashion. They should all be completely excised & examined by a pathologist because a significant number contain squamous cell carcinoma at the base of the horn. If the horn is just shaved off at the skin surface the base with a possible cancer may be left behind.
Cyst(sist)-a sac not normally present that
contains gas, fluid or semisolid material. Superficial skin cysts are
1)superficial skin cells (epidermoid cysts) that have been driven down to a deeper level where they are considered foreign & your body confines or walls off (the cyst walls)
2)plugged glands (sebaceous cysts) that normally produce lubricants etc. for the skin surface once plugged the gland expands & its walls become the cyst walls
The only way to definitively treat a persistent cyst of this sort is complete removal of the cyst contents & its entire wall. If you leave any portion of the cyst behind it will recurr. If you leave multiple fragments you will have more than one cyst when it recurrs. Drainage is only used if the cyst/overlying skin are actively infected. In these cases the infected skin will not hold a suture. The treatment then is to drain some of the cyst contents (bacteria & infectious material) & take oral antiobiotics to allow the infection to clear. Once the infection is resolved the cyst is definitively treated by surgical excision. In some cases the cyst becomes infected & drains on its own. The treatment is then to keep the area clean & maintain an opening for continued drainage. The cyst walls will eventually collapse & the skin opening then close or heal over. The resulting smaller cyst should then be removed because of the high likelihood it will again become infected.
Dermabrasion(der-ma-bra'zhun)-abrasion of the skin surface performed using an apparatus with a wire brush, sandpaper like material or other rough surface. The outermost layers of the skin are abraded or rubbed away. After the area heals the skin is smoother & may be lighter in color. It is commonly used on facial acne scars & aging wrinkles of the lips. Since the early 1990s laser has taken the place of dermabrasion in most cases as the preferred method of denuding the skin surface. Laser allows better control of the depth of skin injury & is associated with less pain after surgery than dermabrasion.
Dermatochalasis(der'ma-to-ka-la'sis)-the presence of excess eyelid skin. This contributes to the appearance of upper & lower eyelid bags. In the upper eyelid the bags seen are usually some combination of dermatochalasis which is treated by blepharoplasty & brow drooping which is treated by a browlift.
de Quervain's Disease-tendonitis of the extensor tendons to the thumb. It is present when bending the thumb into the palm of the hand and grasping it with the fingers, and then bending the wrist away from the thumb side recreates the symptoms.
Dermologen-an injectable form of human collagen obtained from the same cadavers as Alloderm. This material does not require an initial test dose for allergy as does the commonly used cow collagen. It most likely lasts longer than injectable cow collagen but probably not as long as the collagen sheets(Alloderm). Like the other types of collagen it is used to lessen facial wrinkles, scar pit depth & skin folds.
Deviated Septum-see Septal Deviation.
Dorsal Hump-refers to the bump on or prominence of the nasal bridge. This dorsal hump is usually taken down or diminished during Rhinoplasty surgery.Double Eyelid-Many Asians have puffy upper eyelids & no visible upper lidfold, a feature nearly always present in Caucasians. Eyes without the fold are referred to as "single eyes or eyelids" those with the fold as "double eyes or eyelids". In the caucasian upper eyelid the deeper layers of the eyelid converge 6 to 8mm above the eyelid margin/eyelashes & 3 to 5mm above the upper edge of the eyelid cartilage to create a fold. In the asian upper eyelid these layers do not converge so there is no fold. Additionally the fat descends into the eyelid giving the puffy look that is seen in asian eyelids. The surgical procedure to correct this involves removing some of this fat & suturing these layers as well as the skin of the eyelid to the upper edge of the eyelid cartilage in order to create a fold. The puffy look is thereby also diminished. The suture used is absorbed by the body but the healing process keeps the new point of convergence intact. The result is creation of a double lid.
Double Lumen Breast Implant-Double lumen refers to the presence of one silicone shell completely contained within another hence 2 lumens. Currently 2 types are available. The external bag contains silicone gel. The internal bag can be filled with saline. A filling tube with external reservoir is attached to the implant, traverses the outer bag & ends in the inner bag. It is used mostly when the doctor &/or patient is unsure of the final volume needed. The only time I have seen it used is in patients with developmental anomalies where one breast is much much smaller than the other. The final volume is hard to assess before surgery & the implant allows a range of filling of the inner bag with saline. There are 2 types of double lumen implants one is 50:50 saline to gel the other is 25:75 saline to gel. The valve & reservoir can be hidden under the skin for volume changes after surgery & removed in the office under local anesthesia.Dupuytren's(du-pue-trahn'z) Disease-is confined to Caucasian races & is most common in northern Europeans or those of northern European descent. The predisposition to Dupuytren's diseases is genetically inherited & much more common in men than women. Usually women develop the disease later in life with slower disease progression. Disease incidence is greater in epileptics, alcoholics & those with chronic lung disease. In the course of the disease scar tissue is laid down by scar producing cells at variable levels under the skin on the palm side of the hand &/or sole side of the foot. The scar tissue is initially evident as hard nodules palpable under the skin surface that do not affect range of motion. Longitudinal bands of scar tissue into the fingers or toes form over time & eventually begin to contract pulling the digit down into a flexed position. A strong predisposition is present in those with many family members having the disease, disease onset at an early age, severe disease, disease on the backs of the hands & feet or disease recurrence soon after surgical treatment. In very severe disease the scar tissue can choke off blood supply to the overlying skin making it more susceptible to trauma & infection.
Ear Pinning-see Otoplasty
Ectropion-a turning out or eversion of the edge of the usually
lower eyelid away from the eyeball. There are 4 types
1)involutional-is due to laxity or loosening of the supporting structures due to the aging process.
2)cicatricial-is due to scarring & deficiency of eyelid skin/muscle. It can be seen after burns, trauma, blepharoplasty, etc. In the case of blepharoplasty it may resolve on its own within a few months as the swelling completely resolves &/or with the help of massage. In some cases additional surgery is required.
3)complex-is due to scar formation between the different layers of tissue in the eyelid & surrounding the eye.
4)paralytic-is due to paralysis of the muscles surrounding the eye.
Treatment varies depending on the severity of the ectropion & what type is present.
Endermologie-involves the use of an externally applied vacuum
with 2 rotating rollers in the handpiece through which the vacuum is applied
to the skin. The mechanism is much the same as a vacuum cleaner used to
clean rugs. The massaging & vacuum action in essence rupture fat cells.
Leotard type garments are worn during the procedure to minimize bruising.
After multiple treatments (as many as 10 to 15) the end result is much
the same as 1 liposuction treatment for those with minimal to moderate
excess fat to start with. It is not recommended as the sole treatment
for those with marked excess fat. Excessive endermologie can result in
some underlying muscle death as well as fat cell death.
Endermologie has been certified by the FDA for the temporary reduction in the appearance of cellulite. This may be due to the swelling induced by twice weekly treatments & then the requirement of maintenance treatments. There has been no evidence to date that after a certain number of treatments you can stop & will have permanent reduction of cellulite.
Enophthalmos(en'of-thal'mos)-sinking or recession of the eyeball within the bony cavity surrounding the eye. The enophthalmic eyeball appears smaller than the normal eyeball. Commonly seen after large fractures of the bone upon which the eyeball sits.
Entropion-turning inward or inversion of the eyelid margin. The eyelashes may then scratch the cornea.Epicanthal Fold-a fold of skin extending from the root of the nose to the inner edge of the eyebrow above the nose. It can overlap & cover the inner corner of the eye. This is commonly seen in the Asian population & is caused by a deficient nasal bridge. The fold is treated by augmenting the bridge with cartilage or synthetic material. Some surgeons will make small incisions on the edges of the fold to rearrange the skin & make the fold less prominent. This can leave a visible scar in the area as opposed to augmenting the nasal bridge which does not create a scar in the area.
Erythema(er-i-the'mah)-redness of the skin usually due to infection, the normal healing process in new scars, or allergic/skin sensitivity reactions.F
Facelift-a term used to describe the surgical procedure whereby an incision is made vertically down the temple, extended downward just in front of the ear & then brought up the backside of the ear. The skin is then dissected free from underlying structures towards the center of the face. Excess skin is excised from the margin of the incision & then the skin edges are sutured together. The result is removal of excess skin especially of the neck & less so of the cheek & lower face. Facelift is a bit of a misnomer since the neck is lifted more than the face.
Facialplasty-another term for facelift.Fascia(fash'i-ah)-a thin sheet of fibrous tissue that envelopes the body beneath the skin & also encloses muscles or groups of muscles. At the far end of muscles fascia coalesces to become the outermost layers of tendons.
Fascian-a commercially available skin filler consisting of fascia ground up to particles of specific sizes. The particles are mixed with sterile salt water & then injected just under the skin. It is used to lessen facial wrinkles, scar pit depth & skin folds. The fascia is obtained from the same bodies used in organ transplantation
Fat Grafting-involves taking fat from one area usually obtained
by liposuction & injecting it in another area. The grafts have variable
& unpredictable amounts of resorption so that as many as 3 to 6 injections
may be required to achieve a desired
result. The advantage is each procedure is cheap, quick, can be performed under local anesthesia & has little or no downtime/recovery time. I currently reserve free fat grafting to the face for those who have a truly gaunt look or who can't afford/don't like the longer recovery period of a midfacelift.
Felon-a collection of pus in the fingertip that should be surgically drained to prevent spread of infection into the bone or tendon sheath. Infection within the sheath can lead to rupture of a tendon.
Flap-a segment of skin, muscle or bone or any combination of these 3 components used by Plastic Surgeons to close wounds or areas of cancer removal on the body. The flap may maintain its original blood supply or the nourishing blood vessels can be severed. After the tissue is situated in its new position the severed blood vessels are reattached to local blood vessels under microscopic guidance to furnish the necessary blood flow.
Foreheadlift-see BrowliftForeheadplasty-same procedure as Browlift but can include reshaping of the forehead bone. Boney ridges or bossing of the forehead can be shaved down to give a more feminine facial appearance.
Frown Lines-see Browlift
Ganglion Cyst-Adjacent bones are separated by a space or potential
space called a joint. The joint space contains fluid & its boundaries
consist of cartilage covering the bones & ligaments which connect
adjacent bones. The ligaments can weaken forming small outpouches or sacs.
The joint fluid within theses sacs becomes concentrated until the fluid
is of a gel like consistency. This then is a ganglion cyst. Often there
is one main cyst & a few other ones that have not come to the surface.
Although these cysts are benign they are associated with later onset of arthritis especially if the cysts appear early in life. The most common place to see a ganglion cyst is the back of the wrist. Ganglion cysts of the wrist area especially if they arise from more than one joint can be the harbringers of bad wrist arthritis with collapse of the wrist bones. This is due to the weakness of the ligaments in the wrist joints. If the ganlions become large they can impinge on adjacent nerves or affect adjacent tendons.
Treatment consists of:
-sucking out the gel with a needle - very high recurrence rate
-rupturing the cyst with a book - a bible was used in the old days, but this also has a high recurrence rate creating multiple cysts from a single cyst
-surgical excision with removal of the lax ligamentous tissue which also has a high recurrence if only the main cyst is removed leaving behind smaller cyst(s)
Genioplasty-a surgical procedure to change the shape of the chin bone by cutting the bone & changing its position. Genioplasty refers to surgery where the chin bone is actually cut as opposed to chin augmentation with an implant where the bone is not cut. After cutting the free chin fragment is kept attached to the muscle so that it remains live bone. The fragment can be advanced forward & then reattached to the jaw bone with wires, screws or plates to create a more prominent chin. If the chin needs to be lengthened in the vertical direction a wafer of material can be placed along the bone cut line to achieve this goal. If the chin is asymmetric a wedge of bone can be removed from one side or a wafer of material can be placed along half of the bone cut line to achieve symmetry.
Goretex-expanded polytetrafluoroethylene (ePTFE). Goretex has a long & very good history as a blood vessel substitute which I have used many times in the past.
Gynecomastia-enlargement of the male breast. The definition has
nothing to do with what causes the enlargement or what tissue it is composed
of. It is most common around puberty & can be unilateral or bilateral.
Most commonly the enlargement is centralized in the breast but occasionally
it is not.
The classes & causes are
..Newborn-caused by placental hormones & resolves within a few weeks
..Adolescence-caused by alterations in estrogen:testosterone ratio &
usually resolves after puberty (usually within 1 to 2 years)
..Aging (involutional)-caused by testicular failure & treated by testosterone
..Obesity-caused by the conversion of androgens to estrogen in peripheral
fat & treated first by diet/exercise/weight loss
..Deficient production or action of testosterone
..After testicular trauma
..Increased estrogen production
..Tumors within the breast or other organs
..Liver, adrenal or thyroid disease
..A wide variety of prescribed medicines
4. Familial-inborn error of metabolism
The majority of cases are physiological or drug induced. Evaluation by a qualified physician is required to see which category you fall into. The treatment of the physiological category is straightforward while the pathological is more complicated. Drug induced gynecomastia just requires cessation of the causative drug. If the gynecomastia is resistant to treatment or is the adolescent type but persistent surgery is required. Gynecomastia arising before the onset of puberty requires a vigorous diagnostic workup because of the possibility of life threatening or shortening pathology.
The type of surgery depends on the type of tissue contributing to the breast enlargement
..glandular: requires surgical removal of glandular tissue
..fatty-glandular: requires surgical removal of glandular tissue with or without removal of adjacent fat to give the best overall shape
..simple fatty: requires diet/exercise for weight loss, possibly removal of the fat
Fat removal can be accomplished by direct excision with or without liposuction. It can be very difficult to discern how much of the excess tissue is fat vs. gland on external physical exam, even by very experienced people. Also if the breasts are very large & ptotic excess skin will also have to be removed in order to achieve the best aesthetic result. The only exception to this is when surgery is performed before the onset of puberty in which case continued growth will catch up the excess skin. Almost no cases of gynecomastia are adequately treated with liposuction alone. Also the glandular portion of gynecomastia is unaffected by diet or exercise.
Hemangioma(he-man'ji-o'mah)-A mass created from the proliferation
of blood vessels. The first sign of this is a red or blanched spot known
as a herald spot which was not present at birth. This spot rapidly grows
at a rate faster than the general growth rate of the child. After the
phase of rapid growth is completed the color begins to fade & central
area(s) of pallor develop. This heralds the beginning of involution or
resolution. They do not usually invade adjacent structures such as bone
or muscle. By age 5 about half of these children have had full resolution
& by age 7 about 75% of these children. The speed & completeness
of resolution are independent of hemangioma size, location or initial
growth rate. However, the earlier resolution begins & the more rapidly
it occurs the more complete it is.
Resolution may be incomplete & if even complete may leave behind unsightly damaged skin. The classic approach was to do nothing but wait for resolution the thought being that the high percentage of complete resolution was better than risking the chance of scarring after excision. The exceptions were early treatment of ulcerated bleeding hemangiomas or those obstructing vital organs such as the anus, mouth, ears, eyes or respiratory pathways. Rarely the larger hemangiomas can trap blood components giving rise to dangerous bleeding tendencies. The emergency treatment for this is compression dressing to force these components back into the blood stream. Other treatments for hemangiomas have included surgical excision (of the hemangioma or residual damaged skin), laser, steroid injections & interferon injections. Recently early excision has been popularized but this is not always the best route for the reasons given above.
Hematoma(he'ma-to'mah)-a collection of blood outside the blood vessels but still confined within the tissues or organs of the body. This blood is usually completely or partly clotted. They can arise as a complication after any surgery especially if the patient is on blood thinners or after a traumatic injury. All large hematomas should be surgically drained especially those under skin elevated in a facelift, breast reduction or abdominoplasty. Ignoring expanding hematomas in these settings can lead to death of the overlying skin & a poor cosmetic result. Small hematomas may be resorbed by the body or aspirated with syringe & needle after the hematoma liquifies (usually 7 to 10 days).
Hidradenitis (hi-drad'e-ni'tis)Suppuritiva-inflammation of the apocrine sweat glands which are limited to the armpits, groin & pubic areas & the crease under the breast. The glands become plugged. Bacteria then proliferate in the glands creating abscesses. The problems are these specific glands, the material they secrete & the way in which they secrete it. The treatment for active infection is incision with drainage of the pus. The cure is to cut out all sources of infection & closure of the resultant wounds. If the wounds are large skin grafts or preferably skin flaps may be required. Hence the need for a plastic surgeon. The armpit is more commonly affected in women & the groin more commonly in men. The exact cause is unknown but there appears to be a hormonal influence.
Hydroquinone-the active ingredient in most skin bleaching creams. Hydroquinone inhibits the production of skin pigmentation without causing permanent damage to the cells that produce the pigment. Chemical peels can produce the same effect but create some degree of permanent damage to the cells. Since there is no permanent damage stopping the hydroquinone results in the eventual return of pigmentation. Low concentrations of hydroquinone are present in over the counter cosmetics. Higher concentration applications can only be obtained by a doctor's prescription in the United States. In cases of resistant pigmentation Retin-A and steroids are also applied to lighten skin color.
Hydroxyappetite-a natural mineral structure that closely resembles the crystal lattice structure of calcium & phosphorus in bones & teeth. It has been used for many years in surgery to augment the facial bones. Bone adjacent to the hydroxyapatite grows into the material eventually replacing it with viable bone.
The material is available as a slurry or as blocks. It is difficult to work with as it is virtually impossible to pass the slurry through a syringe. The slurry has to be spread like spackle or peanut butter. Additionally, the shape of the slurry can change in the first few weeks after placement. Thus, one has to repeatedly push it with fingers to maintain the desired shape. The blocks are brittle and hard to shape without cracking. The blocks though make ideal interposition grafts between 2 adjacent edges of bone when bone lengthening is desired.Hypertrophic Scar-a ridge or string like segment of scar seen within the confines of the original wound. The techniques used to make these scars less noticeable include changing scar direction so it lies within a normal skin crease or fold, debulking procedures, scar taping, scar massage, local steroid injection, medical grade skin tatoos, dermabrasion, collagen injections, chemical peels, cryosurgery, application of a pressure dressing or silastic sheeting, laser treatments & separation of the skin scar from deeper structures. Which technique or combination of techniques to apply for the best result requires a qualified trained physician. see Scar
Infracture-term used to describe the part of nasal surgery where the nasal bones are moved inward (towards the midline of the face) to narrow the nasal bridge.
Jowl-the fleshy part of the cheek that begins to hang below the lower edge of the jaw as one ages. The front edge of the jowl is the marionette line.
Keloid-large sometimes dumbell shaped scars that grow out of the confines of the original wound. Keloids in general require debulking (if larger than about 1cm in size), steroid injections & pressure garments or earrings. They require long term follow up with the treating physician as they are not cureable only controlable. Surgical removal alone has a very high recurrence rate. Keloids do not respond to silicone sheeting. see Scar
Keratoacanthoma(ker'a-to-ak'an-tho'mah)-a rapidly growing benign tumor of the skin. It resolves on its own in 6 or more months. However, due to the difficulty differentiating this visually & microscopically from skin cancer it is recommended that all keratoacanthomas should be surgically removed.L
Lagophthalmos(lag'-of-thal'mos)-Lid Lag, failure of the upper eyelid to move downward & meet the lower eyelid on attempting to close the eyes. This is most commonly seen after nerve damage such as a stroke paralyzing the muscle around the eye. Treatment can involve removal of scar tissue or addition of skin as a skin graft or placement of small gold weights under the eyelid skin depending on the cause of the lid lag.
Laser(la'zer)-a device that produces a beam of non-spreading light of a single wavelength/color (light amplification by stimulated emission of radiation). The wavelength produced & therefore the laser's effect is dependent upon the material used to create the laser beam for example ruby crystal, carbon dioxide.
Ligament(lig'a-ment)-a band or sheet of fibrous tissue connecting 2 or more bones or pieces of cartilage. All of the joints of the body have ligaments connecting the bones on either side of the joint. When a joint such as the ankle is sprained some of these ligaments are torn. If the tearing is severe enough joint stability is lost & the joint dislocates.
Lipoma(li-po'mah)-a benign tumor composed of fat cells. Noone
knows the exact cause but there seems to be at least 3 types of benign
lipomas. One is reported to occur after localized trauma. It appears as
a single lipoma & is very slow growing. Another is an angiolipoma
which tends to occur in multiple areas all over the body & has more
blood vessels within it. It is due to a genetic predisposition & grows
even more slowly. Another rare form occurs within muscles & is even
less well understood. Some authors have recommended removing the actual
muscle as well as the lipoma because of a high recurrence rate if just
the intramuscular lipoma is removed.
They are benign but can cause problems if they grow to a sufficient size to compress adjacent structures such as nerves or arteries. Lipomas are a rare cause of carpal tunnel syndrome where the lipoma presses on the median nerve at the wrist. The treatment is to remove the lipoma. The vast majority of lipomas are so close to the skin surface that they will never cause a problem other than a cosmetic problem.
Lipoma removal is cosmetic surgery however many times one can't tell the difference between a lipoma & a cyst or other tumor. I had one patient whose presumed lipoma turned out to be a metastatic melanoma cancer. Thus, I think most health insurance carriers cover their removal because you never know what your dealing with until the pathologist's report is complete. My preferred method of lipoma removal especially in the case of multiple angiolipomas is liposuction - the incisions are much smaller & can be hidden in strategic areas. Lipomas can recurr after liposuction since one can never be sure that the liposuction removed every bit of the lipoma but the tradeoff of less scarring is worth it especially in the case of angiolipomas. However, if you are not sure you are dealing with a benign lipoma conventional excision is a better approach to prevent spread of a possible malignancy or liposuction induced cell damage which in turn prevents accurate diagnosis by the pathologist.
Liposuction-Cellulite is due to sagging skin that is pitted on the surface by connections to deeper structures at a different level. Since fat removal does not make sagging skin stop sagging neither liposuction nor endermologie will effectively treat cellulite. In fact some malpractice insurance carriers require consentforms that state cellulite is not affected by liposuction in order to cover liposuction procedures. Liposuction leaves much smaller scars where the liposuction cannula or tube enters the skin. These scars are much easier to hide in hair baring areas of the groin etc.
Local Anesthesia-the form of anesthesia most commonly used for small surgical procedures. The area is injected with anesthetic much the same as the dentist injects the mouth to work on the teeth. The protective reflexes are not hampered; blood pressure, heart rate & other vital signs do not need to be monitored; the patient remains fully awake during the procedure.
Love Handles-the area of localized fat deposits above the hips on the sides of the torso in line with area known as the small of the back (flanks).Lymphedema(limf'e-de'mah)-swelling due to obstruction or destruction of lymphatic vessels or lymph nodes. An example would be arm swelling after breast & armpit lymph node removal for breast cancer. Lymph is a clear fluid containing protein & white blood cells. It flows back from the extremities in lymph vessels & mixes with vein blood near the heart. After passing through the heart & lungs it travels back to the extremities in arteries. This flow of lymph increases when the extremity is injured or infected. The treatment for lymphedema is compression garment application & deep massage of the tissue to facilitate flow in the lymphatic vessels. Lymph nodes are nodules present in certain parts of the lymphatic vessels. They are the site of white blood cell replication.
Macrogenia(mak'ro-je'ni-ah)-a large chin. If a line is drawn from
the midpoint of the nasal bridge tangent to the front edge of the upper
lip this line should touch the front edge of the chin in a male. In a
female the chin should be back about 5mm from this line. If the teeth
are not properly aligned the entire jaw may protrude rather than or in
addition to the presence of a large chin-underbite.
Malar Pouches-puffiness or bulges present over the cheek bones separate from the eyelids. This condition is not treated by blepharoplasty since the problem does not involve the eyelid. In some cases fat deep to the part of the eyelid muscle below the lid itself herniates through the muscle to a more superficial position & is visible from the outside as a pouch. This can be treated by liposuction as it is not eyelid fat.
Mallet Finger or Mallet Deformity-inability to extend the finger
joint closest to the fingernail.There are a variety of causes of this
condition such as arthritis, trauma etc.. Most commonly it is trauma &
in this case scenario the treatment is straightforward. After the inciting
trauma the extensor tendon crossing the last finger joint is ruptured.
Since there is no longer any extensor pull to counteract the flexor tendon's
action the finger tip remains in a flexed position.
The good point about this injury is that the nature of finger anatomy is such that the ruptured ends do not retract-they remain in close proximity. Thus the problem can be effectively treated with an aluminum finger splint that prevents flexion of this last joint. The rupture endings are then kept close together & the rupture heals in about 6 weeks. After 6 weeks the splint is removed & if the problem hasn't resolved it is placed back on for an additional 6 weeks. For the vast majority of patients this is sufficient. A minority require surgical reconstruction after this trial of splinting. It is important though to start the splinting right after the injury in order to get the best result. Some patients also require hand therapy to increase range of motion after the splinting period.
The exception to this treatment is the presence of a significant fracture in addition to the tendon rupture. That is why an x-ray should always be obtained & the treatment should be supervised by a qualified hand surgeon.
Mammoplasty-any plastic surgery procedure performed on the breast
for example Reduction Mammoplasty=breast reduction surgery
Augmentation Mammoplasty=breast enlargement surgery
Mastopexy-Plastic surgery performed to
lift the sagging breast. Breast sagging is usually treated surgically
by removing excess skin resulting in a firmer breast. Because the problem
is related to the skin & breast tissue (fat & breast gland &
suspensory ligaments) rather than muscle this problem is unaffected by
exercise. Whether a lift should be performed or not & what type of
technique is used (around the areola/nipple vs an
inverted-T incision) is dependent on the degree of drooping not the size
of the breast. The normally positioned nipple should be in line with or
above the level of the infra-breast skin crease i.e. while standing upright
the nipple should lie 20cm (about 8inches) diagonally from the neck notch
of the upper edge of the breast bone.
If the breast appears to droop but lies close to the infra-breast crease level an implant is recommended not a lifting procedure. A lifting procedure won't work in such cases & you will end up with a scar for nothing. The implant is placed slightly lower on the chest wall so that the nipple once more becomes the point of maximal projection. For greater degrees of drooping this can't be done because then the implant would lie too low. For minor drooping where the nipple needs to be raised less than 2 inches I prefer the donut mastopexy/breast lift. This leaves a much
less noticeable scar around the nipple complex rather than the inverted T incision that is required if breast drooping is more severe.
Depending on your age & breast size it sometimes is not a good idea to get an implant in the face of severe preoperative drooping. This is because the cause of drooping is multifactorial:
* breast size
* genetic predisposition
* smoking history
* bra use history
If you are already large busted & get a lift with an implant your problem will recur quite readily. As it is a lift procedure alone may have to be redone within 5 to 10 years because the procedure does not affect aging, breast size, genetic makeup or gravity. You can help prevent the recurrence of drooping by regularly using a bra.
Medpor-a synthetic polythelene that is available in a variety of shapes & thickness. It is used to augment bone such as cheek, chin or jaw implants. Thin pieces can be used as cartilage substitutes in nasal surgery. The material is porous so that within one to two weeks blood vessels & tissues grow into & through the material. This ingrowth makes the material highly resistant to infection.
Melanoma-Characteristics indicative of malignancy are skin ulceration, chronic drainage, recent noticeable change in an old skin lesion, recurrent skin infections, variegated or mixed coloration, irregular borders or surface & large size (more than 5mm). These lesions require biopsy. Also, any tissue removed should be sent to a pathologist for examination because physicians are commonly surprised by what looks benign but ends up being malignant.
Melasma-a light tan to dark brown pigmentation of the face (cheek, forehead) in a mask like configuration. It is commonly seen in pregnant women or those taking birth control pills. The pigment lies at a deeper level than the depth reached by pigment lasers. It is best treated with creams as pigment lasers can lighten the more superficial skin & make the lesion look darker.
Mentalis Strain-dimpling of the chin skin seen when the lips are touching. It is caused by a retruded or small chin (Microgenia) & the need for the chin muscles to strain in order for the upper & lower lips to touch. The treatment is to place a chin implant.
Microdermabrasion-a technique used to remove superficial layers of the skin that employs a vacuum & sand like crystals (usually aluminum oxide). The crystals pass over the skin surface abrading it much like a sandblaster cleans the side of a building. This has been referred to as the Parisian Peel. The depth of abrasion is dependent on the length of time of application, strength of the machine used & machine settings.
Microgenia(mi'kro-je'ni-ah)-a small chin. If a line is drawn from the midpoint of the nasal bridge tangent to the front edge of the upper lip this line should touch the front edge of the chin in a male. In a female the chin should be back about 5mm from this line. If the teeth are not properly aligned the entire jaw may be retruded rather than or in addition to the presence of a small chin-overbite.
Micrograft-refers to hairgrafts containing only 1 or 2 hairs per
Mid-facelift-In the early 1990s when
lasers first became popular they were used on every wrinkle &
very patient. Since then most doctors have learned that laser resurfacing
works best for specific problems in specific types of patients. Since
the laser beam only penetrates a microscopic distance beneath the skin
surface it cannot address any problems caused by deeper structures such
as muscles. Thus laser resurfacing at best only temporarily addresses
dynamic facial wrinkles caused by the movement of underlying muscles.
During the aging process the lower eyelid skin thins revealing deeper
structures & develops dynamic wrinkles. Laser resurfacing in my experience
will not permanently remove these wrinkles & cannot thicken this skin.
The wrinkles return within 1 to 2 years. I know of no creams that address
this problem either. The only way to rectify this problem is to remove
the thinned aged skin. The ability to remove this skin is limited by the
degree of eyelid laxity etc. By recruiting some cheek skin up into the
lower eyelid & tightening the lower lid sling a greater amount of
this thin aged skin can be removed. This procedure is called a midfacelift
& furnishes additional rejuvenating properties by blunting the contrast
between the lower eyelid margin & the cheek & by making the skin
folds between the corners of the nose & mouth (nasolabial folds) more
shallow. In some of the fashion magazines this has been referred to as
the vertical facelift.
You can assess how this would look on yourself by pushing the cheek skin adjacent to the nose straight up with one finger & pulling the cheek skin directly over the cheek bone upward & outward obliquely near the outer corner of the eye at the same time.
Milia-a small whitish cyst close to the skin surface. It consists of skin surface cells that have been driven down to a deeper level & have been walled off as they are considered foreign in this position. This can occur after any surgical or traumatic injury to the skin. The cyst is unroofed with a small needle & the contents released. This heals without scarring & recurrence is rare.
Mole -brown pigmented areas on the skin that can be a number of
benign (aging spots, scars, old or chronic collection of blood under the skin from venous stasis or after traumatic, seborrheic keratosis, freckles, melasma, moles or nevi) or malignant (basal cell carcinoma, melanoma). They can be congenital (present at birth) or acquired/arise later in life.
Aging spots are due to the gathering of skin pigment cells into patches or blotches as a result of aging & sun exposure, most commonly on the back of the hands. Freckles have the same etiology & are found in younger people or redhaired individuals. They are best treated with 1 or 2 ruby or yag Q-switched laser treatments. These can be performed with local or topical anesthetic. If large areas of the face are involved the CO2 or erbium laser is a better bet as the extra benefit of overall facial rejuvenation is achieved.
Seborrheic keratosis has a stuck on the skin appearance with an uneven non-ulcerated surface. It is treated by CO2 laser or surgical excision or freezing.
Melasma is a light tan to dark brown pigmentation of the face (cheek, forehead) in a mask like configuration. It is commonly seen in pregnant women or those taking birth control pills. The pigment lies at a deeper level than the depth reached by pigment lasers. It is best treated with creams as pigment lasers can lighten the more superficial skin & make the lesion look darker.
Moles are effectively lightened with ruby or yag lasers but require 2 to 6 treatments. If they are elevated they will need levelling after pigment removal by shaving or CO2 laser. Alternatively they can be shaved level with the skin surface & the base frozen with liquid nitrogen to prevent regrowth. It is hard to impossible to remove a large protruding lesion by liquid nitrogen alone. Also, if the liquid nitrogen is held to the skin for too long (more than 10 to 15 seconds) all the pigment cells may be killed resulting in an unsightly white spot.
Characteristics indicative of malignancy are skin ulceration, chronic drainage, recent noticeable change in an old skin lesion, recurrent skin infections, variegated or mixed coloration, irregular borders or surface & large size (more than 5mm). These lesions require biopsy. Also, any tissue removed should be sent to a pathologist for examination because physicians are commonly surprised by what looks benign but ends up being malignant. Current recommendations are that all congenital moles should be removed & sent for examination by a pathologist because of the inherent risk of cancerous degenaration in congenital moles.
In short if over the counter creams do not yield a prompt response it is best to see a qualified physician to be on the safe side. Any suspicous lesions should be biopsied & sent to a pathologist for examination to avoid missing a skin cancer.
Mondor's Disease-thrombophlebitis (blood clotting within & inflammation
of a vein) of the thoracoepigastric vein. This vein runs along the side
of the torso from the belly button level (where it receives venous blood
from the superficial epigastric & circumflex iliac veins) up to the area
of the armpit where it empties into the subclavian vein directly under
the collar bone. Mondor's can occur spontaneously or after any type of
trauma including breast surgery. It manifests as a warm tender area around
the vein in the uper outer quadrant of the breast or in the skin fold
just beneath the breast. The skin may be pitted with swelling & the vein
may feel like a tender warm cord. The condition is listed in the Plastic
Surgery textbooks as a possible complication of breast augmentation. Most
cases apparently resolve spontaneously but most patients are probably
placed on antibiotics & warm compresses when diagnosed. It is a rare condition.
Nasal Valve-anatomically designated areas in the nose. One is
the internal valve present in each side of the nose at the upper edge
of the hair bearing area inside the nose. The outer valve is at the edge
of the nostril rim. The valves work together keeping the airway open but
can potentially collapse giving rise to diminished airflow on inspiration.
The treatment for nasal valve collapse is to furnish additional support
to nasal architecture in the form of bone, cartilage or synthetic material.
Nasal Septum-see Septal Deviation
Nasolabial Fold-the skin folds between the corners of the nose & mouth. The current methods of treating nasolabial folds include free fat grafts, placement of human collagen sheets (Alloderm), placement of Softform goretex tube & mid-face lifting. Each has its own advantages & disadvantages. With Alloderm or free fat grafts there is a very short recovery time with little or no bruising or swelling & only antibiotics are required should an infection arise. Fat grafts have variable & unpredictable amounts of resorption so that as many as 3 to 6 injections may be required to achieve a desired result. The disadvantages of Alloderm are cost & permanence cannot be guaranteed. So far we know Alloderm lasts at least 2 or 3 years. The Softform only affects mild to moderate depth folds because the tube is only 3mm in diameter. For more severe folds this 3mm does not have a very visible affect. Additionally, should an infection arise the Softform must be removed & antibiotics taken. Despite these minor disadvantages I have had many happy patients who have had Softform placed in the nasolabial folds. Mid-face lifting is a more involved approach which treats the cause of the folds rather than just trying to cover them up. The cause is loosening of some skin attachments to the underlying tissues & downward shifting of cheek fat which then hangs over the crease (another attachment that does not loosen) creating a deeper fold. This approach not only decreases fold depth but also resuspends the cheek fat. The disadvantages are the need for general anesthesia, a longer downtime/recovery time & cost.
Nerve Compression-Contrary to popular belief the treatment for nerve compression (such as carpal or cubital tunnel) is not always non-steroidal antiinflammatory agents or NSAIDS (such as aspirin) with splinting followed by surgery. The treatment is dependent on the stage of compression.
Early compression with intermittent symptoms is treated conservatively with splinting, NSAIDs & alteration of workhabits/ergonomics.
Moderate compression with intermittent but progressing symptoms & measurable deficits is treated much the same as early compression but more aggressively.Severe compression with persistent symptoms (such as fingers numb all the time), muscle wasting & abnormal measurable deficits should be treated by surgical decompression period. Every moment of delay results in irreversible damage to more nerve tissue.
Neuroma(nu'ro'mah)-a tumor consisting of nerve cells. It is commonly used as a shortened term for traumatic neuroma. This occurs after amputation or other injury to the nerve. In an attempt to regrow a benign nerve tumor appears at the end of the nerve. This can be so sensitive to touch as to be incapacitating. In these cases surgery is performed to debulk the tumor & then bury the end in muscle or a hole in the bone where it is protected from outside stimulation.
Osteomyelitis (os'te-o-mi-e-li'tis)-inflammation/infection of
bone including the bone marrow & the membrane covering the bone (periosteum).
Minor cases resolve with a course of antibiotics alone. More severe cases
require surgical removal of dead/infected bone.
Otoplasty-is performed via an incision behind the ear. In some cases some cartilage is removed. In all cases non-absorbable sutures are placed to reshape the cartilage. As many as 4 or 5 sutures may be placed in one ear. This is done the office operating room under local anesthesia with some additional pills given to relax the patient. A wrap around head dressing is worn for 1 or 2 days. After that a commercially available head band such as those worn while playing tennis is worn constantly for 1 month, except while bathing. This is because the sutures holding the cartilage in position are not that strong & the headband acts as an external splint to support the sutures thereby preventing rupture of the shaping sutures. After this month the headband should be worn intermittenly for example when sleeping or not out in public for 6 or more months. Because the shaping sutures frequently snap or loosen some minor adjustments or replacement of 1 or 2 sutures is frequently required. About 50% of patients need these additional smaller re-shaping procedures.
This procedure is cosmetic surgery & not covered by any health insurance. You can see some before & after photos on my website.
Paronychia(par-o-nik'i-ah)-infection of the cuticle of the finger. In its early stages it can be treated by antibiotics alone but more advanced infections require drainage of the pus contained in the paronychia.
Pectus (pek'tus) Carinatum -pigeon or keel chest. Flattening of the chest on either side with forward projection of the breast bone.
Pectus (pek'tus) Excavatum -funnel chest. It is usually
noted after birth but in some people it is not visible until they are
older as the deformity can be unpredictably progressive. The exact cause
is not known but it is more common in males than females. It is believed
to be due to overgrowth of the rib cartilage adjacent to the breastbone
(sternum) which pushes the breastbone backwards. Most people have no symptoms
but if the breastbone is pushed back far enough heart & lung function
can be compromised. One could then have curvature of the spine, shortness
of breath on exertion, heart palpitations, limitation of ability to perform
strenuous activity. Surgery is required for cosmetic reasons & in
more advanced cases to improve heart & lung function.
Infants with compromised heart/lung function should undergo surgery early. This involves cutting the breastbone & rib cartilage & either flipping the breast bone over or making cuts to allow bending of the bone. A recent surgical advancement involves making 2 small incisions on either side of the chest. Using endoscopic guidance to free up chest tissues & then inserting a metal bar that pushes the caved in area forward. A few months later the bar is removed. The surgery is simpler, has a quicker recovery time & gives as good or better results. For smaller purely cosmetic deformities (no functional deficit) especially in adults custom made implants are used to camouflage the defect. Because of the great variablity of deformity among those who have this deformity the implant must be custom made. A plaster model is made of the deformity in the plastic surgeon's office. The model is then sent to the manufacturer who makes a custom silicone implant. The implant is inserted via a horizontal incision in the natural crease between the chest & abdomen. Because the actual bone depression may be smaller than the grossly visible external surface defect some intraoperative adjustment of the implant may be required.
Pharyngeal Flap-a flap of tissue raised in the back of the throat & surgically attached to the palate in order to prevent food from coming up into the nose as well as allowing improved speech in cleft palate patients.
Phenol-a chemical used as a chemical peel to destroy the outermost layer of facial skin. The liquid is applied to the facial skin & it is absorbed through the skin into the blood stream. In order to avoid the toxic effects of a large dose the solution is applied to the face in a segmental rather than continuous fashion.
Post Inflammatory Hyperpigmentation-refers to darkening of the skin after skin surface damage in darker complexioned individuals. It usually appears between 4 & 6 weeks after injury. In some cases it is very dramatic. It is most likely due to increased sensitivity of pigment cells to sunlight, an over done or out of control sun tan. It can be prevented or ameliorated by avoidance of the sun with sunscreen beginning about 2 weeks after injury. At the earliest sign of post inflammatory hyperpigmentation hydroquinone bleaching creams should be started. These usually work within a few weeks but adjustments of the cream strength & frequency of application may be required. In more severe cases Retin-A & a steroid cream may also have to be applied. Sunscreen should be continued while using hydroquinone, usually sunscreen is applied in the morning & hydroquinone at night. Once the normal skin color has returned there is no further need for hydroquinone but sunscreen should be continued for 1 year.
Pressure Sore-wounds or sores of the skin created by pressure
on the skin surface that prevents blood flow to the skin surface. They
are found in bedridden individuals & those paralyzed from the waist
down or from the neck down. Deeper layers are affected before the skin
surface but their damage is not visible until there is skin surface breakdown.
The skin surface hole is thus described as the tip of an iceberg phenomenon
as the full wound is cone shaped. Prevention involves the use of special
wheelchair cushions & mattresses as well as changes in position every
2 hours. The treatment for small sores is local wound care. Larger sores
require surgical excision of the entire wound & closure with flaps
of skin/muscle by a Plastic Surgeon.
Primary Surgery-the first time a surgical procedure is performed for example primary rhinoplasty as opposed to secondary rhinoplasty. The former would be the first nasal surgery. The latter would be later operations to correct the first surgery or to make additional changes to the nose.
Ptosis(to'sis)-a falling, drooping or sagging body part. For examples breast ptosis or eyelid ptosis for drooping breasts or eyelids.
Pyogenic Granuloma-non-cancerous rapidly developing or growing vascular lesions that lie above the level of the surrounding skin. They are usually round, red & stop growing before reaching 1 centimeter in diameter . They bleed freely on slight trauma & are most commonly found on the face, chest or fingers. They consist of microscopic blood vessels(capillaries) & scar tissue covered by surface skin cells. A minor traumatic incident that is usually forgotten precedes their development. The treatment is removal by simple excision, scraping(curettage) or laser. They need to be completely removed to decrease the chance of recurrence & the best way to ensure complete removal is excision.
Raynaud's Phenomenon-Syndrome-episodic hand & finger blood
vessel spasm seen in response to cold temperatures or emotional stimuli
without an underlying cause. The fingers then become pale or discolored.
Running cold tap water over the
fingers rapidly produces these signs. The Syndrome can be associated with a number of factors such as immunologic & connective tissue disorders, occlusive blood vessel disease, frostbite, chronic cold exposure, vibratory trauma such as jackhammer use & certain drugs. It is important to avoid tobacco & cold exposure as to do otherwise can result in the loss of fingers from inadequate blood flow. Severe episodes should be treated emergently by a physician to prevent permanent damage.
Reconstructive Surgery-surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease so as to improve function or create a normal appearance to the extent possible. By law these procedures must be covered by health insurance carriers.
Reflex Sympathetic Dystrophy (RSD)
Repetitive Stress Injury
Rhinophyma-have been observed for centuries but the term rhinophyma
(from the Greek rhis for nose & phyma for growth) was first used in
1845 by Hebra. It was initially thought to be due to chronic alcohol consumption
but is currently thought to be a severe form of acne rosacea. There is
bulbous enlargement of the nose with a ruddy complexion & numerous
pits along the surface. The sebaceous glands of the nose increase in size
& number with each surface pit being the mouth of a gland. Although
the disease is benign superficial skin infections are characteristic with
drainage of foul smelling material. It is 12 times more common in men
In the early stages accutane may help shrink the sebaceous glands but could adversely effect future surgical treatment of the disease. For more marked disease the treatment is full thickness excision with skin grafting or tangential (partial thickness) excision allowing the skin to heal without grafting. Some surgeons prefer laser excision citing less bleeding among other reasons. Having seen & tried various modalities I think tangential excision with a scalpel under local anesthesia is best. The nature of laser excision makes this more difficult with laser which works from the surface downward rather than tangentially. The nose heals within a week or 2 as the surface is repopulated by cells from the depths of all those pits.
Since the disease is not curable control in the early stages or after surgical excision & healing is of paramount importance to prevent recurrence. This involves continued use of oral tetracycline antibiotics at least a few times a week & meticulous skin cleansing. Avoidance of spicy foods, caffeine & alcohol also may help.
Rhinoplasty-surgery to reshape the nose, is one of the most common
of all plastic surgery procedures. Rhinoplasty can reduce or increase
the size of your nose, change the shape of the tip or the bridge, narrow
the span of the nostrils, or change the angle between your nose and your
upper lip. It may also correct a birth defect or injury, or help relieve
some breathing problems. During surgery the skin of the nose is separated
from its supporting framework of bone and cartilage, which is then sculpted
to the desired shape. The nature of the sculpting will depend on your
problem. Finally, the skin is redraped over the new framework & it
is the adherence to this framework as well as shrinking of the skin
that gives the end result.When rhinoplasty is performed from inside the
nose, closed, there is no visible scarring at all. When an "open"
technique is used and incision is placed on the strip of skin between
the nostrils. When the procedure calls for the narrowing of flared nostrils,
incisions are placed in the creases between the nose & lip or cheek.
When properly performed this does not hamper breathing.
Rhinoplasty can be performed under local anesthesia with sedation or general anesthesia, depending on the extent of the procedure and patient preference.
Rhytidectomy- see Facelift
Scar-An essential part of the body's natural
healing process, scars are the result of the skins' repair of wounds caused
by accident, disease, or surgical incision (hair transplants). The more
the skin is damaged and the longer it takes to heal, the greater the chance
of a noticeable scar. That is why picking at healing wounds only make
them scar worse.
Typically, a scar will become increasingly prominent at first, then gradually fade; many disfiguring marks which seem unsightly at three months may heal quite satisfactorily if given more time.
Scars can be classified as hypertrophic (seen as a ridge within the confines of the original wound), keloid (large sometimes dumbell shaped scars that grow out of the confines of the original wound) or widened & depressed.
A scar's visibility will depend on a number of factors, including its difference in topography or color from the surrounding normal skin i.e. color, texture, depth, length, width or direction. If the skin scar adheres to deeper structures such as muscle or bone the skin may bunch up with animation or movement as it is tethered to deeper structures. How the scar forms will also be affected by an individual's age and by its location on the body or face. Younger skin, for instance, makes strong repairs and tends to over heal, resulting in larger, thicker scars than on older skin. Skin over the jawbone is tighter than skin on the cheek and will tend to increase a scar's prominence. If it is depressed, it will make skin seem shaded, and if it is higher than surrounding skin, it will cast a shadow. A scar that crosses natural expression lines will be visually striking because it will not follow a natural pattern, and a scar that is wider than a wrinkle will stand out because it is not a naturally occurring line.
Any one, or a combination, of these factors may result in a scar that, although healthy, may be improved functionally or cosmetically by treatment. The techniques used to make scars less noticeable are changing scar direction so it lies within a normal skin crease or fold, debulking procedures, scar taping, scar massage, local steroid injection, medical grade skin tatoos, dermabrasion, collagen injections, chemical peels, cryosurgery, application of a pressure dressing or silastic sheeting, laser treatments & separation of the skin scar from deeper structures. Which technique or combination of techniques to apply for the best result requires a qualified trained physician. Keloids in general require debulking, steroid injections & pressure garments or earrings. They require long term follow up with the treating physician as they are not cureable only controlable. Keloids do not respond to silicone sheeting. Hypertrophic scars are sometimes treated in the same fashion but are more amenable to laser treatments, silastic sheeting & pressure garments.
There are certain areas such as a good quality scar on the face or neck of an adult male where a tattoo to simulate early beard growth is the best technique. The problem is that most tattoo artists are great when it comes to drawing anchors etc. but not very good at simulating natural skin color or beard growth. Although a repaired laceration or incision heals so that it won't come apart within 14 days it takes months to mature. During the maturation phase which can last up to 8 or 10 months the scar is malleable & sensitive to external treatments as well as local skin surface tensile forces. These forces can be distracting causing the scar to widen or parallel to the length or height of the scar causing scar thickening. There can even be a combination of forces. These forces are greatest in areas where the skin is not lax i.e. it is difficult to pinch a significant amount of skin. Just try this on your chin, knee cap area with the knee bent or scalp vs.back of the hand or neck. To diminish these forces elective incisions are placed along lines of least tension & patients follow a skin taping or silicone sheet regimen for all incisions/laceration repairs. Thus, you can see that how an incision line is treated for the months following surgery has greater impact on the final look of a scar than the initial stitching procedure. Simple excision of a scar usually does not work. Removal of skin increases tension around the scar & results in a high recurrence rate of unsightly scars. Keloids are not cureable they can only be managed by debulking & then treatment with pressure, steroids etc..
The problem with the facial area in men is they try to grow a beard to hide the scar. The scar then widens & one is left with a bald area. The better treatment is a close shave & taping.
Sebaceous Cyst-see Cyst
Senile lentigo/lentigines-aging spots that are due to the gathering of skin pigment cells into patches or blotches as a result of aging & sun exposure, most commonly on the back of the hands. Freckles have the same etiology & are found in younger people or redhaired individuals. They are best treated with 1 or 2 ruby or yag Q-switched laser treatments. These can be performed with local or topical anesthetic. If large areas of the face are involved the CO2 or erbium laser is a better bet as the extra benefit of overall facial rejuvenation is achieved.
Septal Deviation- The nose is comprised
of 2 nasal airways which lie side by side like 2 rooms with a common wall
& 2 outer walls. The doorways into the rooms are analogous to the
nostrils. The outer walls are made of bone & nasal lining(mucosa).
The common wall contains cartilage in its center (nasal septum) covered
on both right & left sides with nasal lining (mucosa). The cartilage
is analogous to plaster or gyproc in a wall & the lining is analogous
to wallpaper. When the common wall is crooked(deviated septum) it can
block the free flow of air through the nose & block drainage of the
sinuses which drain through the outer walls into the nose. When blocked
the sinuses collect mucous & may become infected.
Most people have some degree of septal deviation but it is not symptomatic. The deviation arises from trauma after birth or can be due to trauma during passage down the birth canal. The deviation is classified as oblique, C-shaped or S-shaped & the surgical treatment is based on which class is present. The oblique is easiest to
treat as only a bottom strip of cartilage is removed (analogous to the baseboard of a
common wall in the example given). The cartilage can then be swung into the midline. C- & S-shaped are more difficult to treat requiring removal of a square of cartilage from the center of the wall while leaving the lining in place & an outer L-shaped rim of cartilage. In some cases internal splints of cartilage have to be placed to keep the cartilage straight as cartilage has some degree of memory & tends to go back to its original shape.
In some cases additional drainage procedures from the sinuses may be required as the opening of the sinuses into the nose is faulty as well.
Septal Perforation-The 5 possible causes of septal perforation
(a hole in the common wall between the 2 nasal airways) are:
1) Traumatic-such as after surgery, a punch, gunshot or knife stab to the nose, nose picking, repeated cautery for nosebleeds
2) Infection-such as typhoid, syphilis, tuberculosis, leprosy, fungus
3) Irritants-such as cocaine(especially if the bone is involved), heroin, nasal sprays, or industrial chemical exposure
4) Cancer(especially if the bone is involved)-such as melanoma, adenocarcinoma, squamous cell carcinoma, lymphoma, cancer metastases
5) Inflammation-such as sarcoid, Crohn's disease, Wegener's granulomatosis, systemic lupus erythematosis, rheumatoid arthritis
A variety of laboratory tests must be performed for non-traumatic causes
of septal perforation before treatment is begun. Only perforations causing
problems or symptoms such as crusting, bleeding, obstruction to nasal
air passage, or whistling noises when breathing need to be treated. Most
do not cause any symptoms.
If cocaine or heroin is the cause the chemical addiction must be treated as well in order to have a successful outcome.
The repair technique chosen depends on the size of the perforation, the location of the perforation and the condition of the surrounding septal mucosa. Prior to attempted repair the condition of the mucosa or nasal lining should be optimized with the appropriate nasal sprays, antibiotics, nasal cleansing regimen and nasal lubrication. Dry crusting nasal mucosa will not hold a stitch & the hole may just get bigger in such situations.
Small holes near the nostrils with healthy surrounding mucosa can be
repaired with advancement of the mucosa over the hole. The succcess rate
of these procedures is improved if additional grafts of tissue from elswhere
on the body are used to help plug the hole. Larger holes will require
more tissue with a separate blood supply. This can be furnished by rotating
a flap of tissue from inside the mouth via the floor of the nostril. Holes
that are far back from the nostril may require temporary separation of
a nostril from the cheek in order to get the necessary exposure to see
the defect. The closer to the nostrils & larger the septal perforation/hole
the greater the likelihood there will be symptoms or problems.
Plastic buttons have been used to plug the holes but they can cause problems such as increased mucus production, crusting and obstruction to airflow.
Skin Tags-benign overgrowths of skin that protrude outward from
the skin surface in a mushroom like fashion. They are easily removed under
local anesthetic & can occur virtually anywhere you have skin but
seem to be most common on the face. Most health insurance carriers consider
their removal cosmetic. But if you have one on the eyelid margin, blocking
the entrance to the ear canal, or affecting function in some other way
or if the tag is infected the removal will be covered (as much/little
as insurance companies currently cover medical problems). Usually their
excision leaves little or no scar & no sutures are needed.
I have removed as many as 10 to 20 skin tags from a patient at one sitting.
Ski Slope Deformity-
Softform-a tubular implant made of expanded polytetrafluoroethylene
(ePTFE or goretex) housed in a sterile insertion trocar apparatus. The
material is placed under the facial skin for the reduction of deep furrows
or enhancement of vermilion border definition. The implant reduces crease
or furrow depth by raising the crease or furrow to the level of the surrounding
skin. ePTFE has been used for more than 20 years in vascular replacement
implants. The use of this material for vascular implants was followed
by clinical application for hernia repair, abdominal wall reinforcement
and subsequently, for soft tissue augmentation.
Because the softform tube is only about 3mm in diameter 1 tube doesn't augment the lips very much. Instead it is used to make the border between skin & the lipstick margin (vermillion border) more prominent. In my experience it works best to treat mild nasolabial folds (those folds between the corners of the nose & corners of the mouth). These patients are the happiest because of the simple nature of the procedure & quick recovery time with appreciable results. More severe folds do not achieve the same results. The trocar apparatus prevents the portions of tube remaining under the skin from touching the skin itself. It decreases the risk of infection & the tube's hollow shape allows growth of tissue into the tube to fix it in position.
Squamous Cell Carcinoma
Stretchmarks-In a fashion similar to an old over used elastic
band collagen fibers under the skin surface break when overstretched.
The result is atrophy of the deeper dermal layers of the skin & a
grossly visible stretch mark. The stretching can be caused by large underlying
muscles or accumulations of fat. This is very commonly seen on the abdominal
skin of women after childbirth. The only way to get rid of the stretch
marks is remove the involved skin as in an abdominoplasty/tummy tuck or
thigh-buttock lift. In some people a flashlamp laser treatment will the
make the stretch marks less noticeable but will not completely erase them.
For the shoulder & armpit area it would not be a good idea to excise the skin unless one has lost a lot of weight & is left with a lot of hanging skin. Thus, laser would be the way to go in this area. It doesn't work in everyone but the cost is minimal, there is virtually no down time, the complications are almost non-existent in light skinned individuals & usually no anesthesia is required.
Subglandular Breast Implants
Submuscular Breast Implants
Suction Assisted Lipectomy or Suction Lipectomy
Swan Neck Deformity
Tendonitis-swelling or inflammation of the tissues surrounding a specific tendon or group of tendons. The inflamed areas are tender to the touch & elicit pain on motion. Application of heat, the use of a splint & the taking of non-steroidal or steroidal antiinflammatory agents are the first line of treatment. This works in the majority of cases especially if applied early on. The second line of treatment is injection of a mild steroid into the tendon sheath. This should only be performed once or twice. If the above fail surgical release of the sheath surrounding the tendon with or without removal of the surrounding inflamed tissue is required. If you just ignore the problem & allow it to progress you may end up rupturing the tendon which is a more difficult problem to treat & has a much longer recovery period.
Thigh Buttock Lift-the thigh & buttock skin is re-elevated by removing a section of skin that lies under what is normally covered by underwear or a bathing suit. The removal is performed circumferentially.
Medial Thigh Lift-This involves removing inner upper thigh skin. The incision is designed to be hidden in the crease where the inner thigh meets the torso. Since this incision is hard to hide & can migrate downward making it more visible this procedure is reserved for patients with a great excess of inner thigh skin. Many surgeons will preferentially perform liposuction & then wait some months to see how the remaining skin shrinks before considering performing a medial thigh lift.
Thoracic Outlet Syndrome-Thoracic outlet refers to the outlet
from the chest that nerves & blood vessels traverse on their way into
the arms. These structures are compressed at the outlet by muscles, squeezed
between collar bone & rib or compressed by extra ribs in the neck.
Significant compression leads to symptoms or thoracic outlet syndrome.
The symptoms are predominantly & primarily neurologic in nature -numbness,
tingling & weakness of the hand especially the ring & small fingers.
Motion especially with the arms up & shoulders back aggravates the
problem. Uncommonly there are symptoms of blood vessel compression.
Treatment is dependent on the symptoms present & cause of compression. In some cases it is posture related & only physical therapy is required. In other cases removal of an extra rib or congenital band compressing the outlet or some other surgical treatment is required. Surgical therapy can be unreliable in the relief of symptoms.
Tissue Expander-a silicone bag that is placed under the skin at surgery and then inflated/injected with salt water usually on a weekly basis to stretch the overlying skin in preparation for additional surgery. This technique is commonly used in breast reconstruction and as part of the surgery to separate siamese/co-joined twins.TRAM Flap
Trigger Finger-The space through which flexor tendons travel down
the fingers is very narrow. As the flexor tendons traverse the palm &
enter the digits they pass through tunnels formed by fibrous tissue rings
that surround the tendon & are connected to the underlying bones.
These fibrous tunnels keep the tendons close to the bone & prevent
bowstringing during normal motion. If any inflammation occurs around the
tendon it cannot slide up & down this narrow space. The tendon becomes
caught in the tunnel or sticks to the tunnel sidewalls. Hence, the clicking
sensation sometimes accompanied by pain on motion progressing to the digit
being stuck or locked in a flexed position in more severe cases. This
process sets up a vicious circle where sticking to the tunnel sidewalls
creates a more severe disease process or more inflammation. There can
be significant pain on attempting to extend or straighten the finger.
Rarely, the finger can become locked in an extended position. The inflammation
is a result of repetitive work trauma as with the chronic use of tools
such as screwdrivers, scissors, typewriters, etc. The majority of these
cases resolve with splinting or alteration in the use of work tools. Persistent
or severe triggering is treated with a single steroid injection that cures
over 70% of cases. The problem is many physicians give the shot improperly
& miss the tunnel or inject directly into the tendon rather than around
it. Uncommonly another injection is required 4 to 6 weeks later. Should
the problem then recurr or be resistent to steroid therapy a surgery release
procedure is required. You should have this problem evaluated by a qualified
physician as soon as possible at it can become incapacitating.
I prefer not to give more than 2 injections & recommend surgery if there is no response to steroid injection or if the problem returns after resolving. Of course, some changes have to be made in hand activities after response to steroid injection in order to prevent recurrence.
Trismus-painful spasms of the chewing muscles that commonly occur after jaw surgery.
Tuberous Breasts-In the tuberous breast deformity the skin of
the lower half of the breast remains attached to the chest wall &
does not grow with the remainder of the breast during puberty. The result
is a breast with less tissue below the nipple than above it & a high
infra-breast skin crease. The developing tissue in some cases may be forced
into or herniate into the darker tissue surrounding the breast nipple
(areola) &/or may be constricted at its base. This may occur in one
or both breasts. The difference between this scenario & small breasts
is that small breasts are symmetrically smaller with respect to the circumference
& center of the breast.
The treatment involves correction of the hernia if present, release of the constricted base & lowering of the attachment of the breast to the chest wall (inframammary or under the breast skin crease) with or without placement of a breast implant. If one merely places a breast implant without correcting the other problems the resulting breast will look far from normal. The deformity may be mild & therefore unnoticed until after breast augmentation which magnifies the deformity. This necessitates a return to the operating room to treat the deformity & improve the look of the breast implants.
Tumescent Liposuction-The history of liposuction is such that it first became popular in France & was performed by Dr. Ilouz. He infiltrated the tissues with fluid & then suctioned out the fat under general anesthesia via incisions hidden in skin creases. This was followed by a period of greater reliance on general anesthesia & less infiltration. Then came a period of greater reliance on infiltration with fluid mixed with local anesthesia. And if some is good more must be better philosophy ensued so a very high volume of fluid was then infiltrated. This made the area to be suctioned swollen & hard hence the term tumescent. The idea behind this was to perform the procedure without general anesthesia or an anesthesiologist to allow the patient to recover more quickly or leave the surgery center earlier & cut costs.
Another reason not usually mentioned is that early proponents of this technique were not surgeons, did not have operating room privileges & could not get anesthesiologists to anesthetize these patients for liability reasons. The infiltration of larger amounts of fluid probably does decrease the amount of postoperative bruising & pain. However, because body contours are severely distorted the practitioner has to be more experienced to gauge where & how much fat to remove in order to obtain a specific result. Also, with the greater reliance on infiltrated fluid for anesthesia shorter & narrower liposuction cannulas had to be used & applied closer to the surface. The reason for this is that despite the local anesthesia there can still be significant pain with longer or wider cannulas passed into the deeper tissue layers. Thus, arose a technique where multiple holes are placed in the area to be suctioned as the short narrow cannulas do not reach very far. Depending on the person & body area these multiple access sites with more superficial suction can cause unsightly scars or uneven skin topography.
In summary be careful about the use of the word tumescent as some people use it to denote slightly different techniques with vastly different results, some of which can be very unsightly. Dr. Stone prefers to use a wet technique rather than true tumescent placing the access sites so they will be hidden in skin folds. Lastly, the end result of any liposuction is dependent more on the condition of the overlying skin immediately after the procedure than the volume of fat removed
Tummy Tuck-see Abdominoplasty
Turbinate/Turbinectomy-The nose is comprised of 2 nasal airways
which lie side by side like 2 rooms with a common wall & 2 outer walls.
The doorways into the rooms are analogous to the nostrils. The outer walls
are made of bone & nasal lining(mucosa). Turbinates are baffles that
extend from the outer walls of the right & left nasal cavities into
the cavity or airway itself. They help to control air flow & humidify/warm
inhaled air. They are composed of a core of bone (a shelf of bone protruding
out of the wall) & are covered by mucosa. If the bone is too large
&/or the mucosa swollen the airway will be blocked preventing air
flow through that side of the nose. The sinus cavity on that side of the
face may also be blocked so it can't drain. This can cause sinusitis,
sinus headaches, etc.. If the problem is intermittent i.e. comes &
goes it most likely is due to swollen mucosa which swell on exposure to
pollutants, pollens & other airborne irritants. If this is the problem
avoidance of irritants & nasal drops/sprays should suffice. It is
critical in the case of chronic sinusitis that an antrostomy (opening
into the sinuses) be done. All too often patients will only have
turbinate reduction done, and still be left with a diseased sinus, when
they should have had more definitive procedures done.
If the problem is constant it is most likely due to excess bone & surgical debulking of the turbinate is required (Turbinectomy). The entire turbinate need not be removed & most of the mucosa should be spared to prevent a dry nose with bleeding etc. after surgery. A sheet of plastic is placed between the septum in the middle of the nose & the sidewall from which the turbinate has been debulked. This prevents scar tissue from forming between the raw surface on the turbinate & the septum. If this scar tissue forms it can also hamper air flow. Packing is not usually required you only need something to prevent the scar tissue bridge from forming.
Ultrasound Assisted Lipectomy/Liposuction-has been introduced over the last couple of years. Initially a solid cannula was introduced & ultrasonic waves used to emulsify the fat which was later suctioned out with a hollow metal cannula. Later the ultrasonic cannula was hollowed to allow both emulsification & suction at the same time. Initially it was thought that ultrasonics resulted in less bruising, less blood loss, greater skin shrinkage & less surgeon fatigue in performance of the procedure. It has seen been proven that there is very little difference in bruising or skin shrinkage. Ultrasonic assisted liposuction results in more noticeable liposuction access site scars, increases the length of the procedure & in inexperienced hands can result in skin burns. My current personal preference is to reserve it for patients who have had prior liposuction or have large volumes of fat to be removed.
Umbilicus-the belly button
Usual, Customary and Reasonable (UCR)-Historically speaking, in
the 1920s or 1930s there was no such thing as health insurance. Patients
simply paid their physicians. With increasing technology, liability &
other costs the average individual could no longer afford health care
& the health insurance industry arose to fulfill a need. There were
separate policies for hospital care & others for health care professionals.
However, patients paid their bills & were reimbursed by their insurance
company. This arrangement changed in the 1950s through 1960s when
insurance premiums rose & insurance companies paid the bills directly.
Copays & deductibles were introduced to prevent overutilization of
services by patients. Most policies were independently purchased by subscribers.
In the 1970s the introduction of better computers allowed the codification of services provided by doctors & hospitals & the diagnoses of patients. Then services supplied by different health care providers could be compared including their fees. Much of this was government initiated to control Medicare and Medicaid budgets. The government set out to assign work units to different codes & say how much it would pay for different codes. The private insurance companies in general were paying 2 to 3 times the amount of the government's corresponding fees. The amount paid per code was based on the usual, customary & reasonable amount in the area where services were delivered i.e. what the average doctor was charging. Simultaneously the government began forcing employers to buy health insurance for their employees & offer HMO plans to them. This has continued to the present so that currently an individual will find it impossible to purchase non-HMO health insurance on his/her own. The risk pool for individual plans has shrunk to the point where it is unprofitable for health insurance companies. Since the insurance companies now had very large portions of the patient pool under their control they began to influence healthcare to maximize their profits by controlling the delivery & cost of care. While the government based its payments on having a fixed amount of money to spend on healthcare & controlling this as a percentage of inflation & GNP the insurance companies thought differently. During the 1990s the government decreased it's fee schedule for procedures dramatically. The insurance companies followed suit dropping from 2 to 3 times the government fee to 1.5 to 2 times. They have continued this to the level of 1.1 to 1.2 times the government fee. In some cases they are offering contracts of 0.6 to 0.7 times the government rate. Coupled with greater than 40% increases in premiums, corrected for inflation in the 1980s & 1990s they are making a bundle. They are picking fee schedules which they call allowed amounts that maximize their profits & pegging them to the government rate. This is particularly troublesome since the government rate relates to federal budgets & has nothing to do with how much it costs to deliver those services. Non-government insurance should not be pegged to government rates.
Calling the amount they think medical services are worth "allowed amount" on the explanation of benefits circulated by insurance companies is misleading if not an outright lie. The column should be labeled what the company will pay for these procedures in order to maximize profits & damn the doctor because we don't care how much it costs him to maintain an office etc.. We also don't care if he makes a profit.
W-plasty -refers to a saw tooth pattern of skin closure after removal of a skin lesion or scar to make the end result scar less noticeable.
Xanthelasma-round or oval slightly elevated yellowish lesions
located on the eyelids. They consist of fat deposits that have been deposited
between the skin & underlying eyelid muscle. They have no significant
relationship to blood cholesterol levels. They are benign. Treatment options
1-excision of the lesion & overlying skin with immediate suture of the resulting skin wound. If the lesion is large skin grafts or local flaps of tissue can be used to close the defect.
2-laser ablation of the lesion & the skin directly on top of it
3-skin incision with removal of fat deposits under magnification. After removal the skin is sutured.
The last option may be better especially for large deposits because skin damage is minimized to remove the fat deposit.