Pain control during surgery has been quite good for a number of decades. Refinements in recovery from anesthesia to lower the incidence of nausea, shaking etc. after surgery have been accomplished by adjusting the mix of anesthetics used and employing newer medications like propofol, toradol, zofran etc. More recently the focus has been on controlling pain after surgery to lessen the need for narcotics, shorten recovery times after surgery and improve surgical results in general. The opioid narcotic medications commonly used can become addictive, have small windows between effective and overdosing quantities that affect breathing and tend to be constipating.
Local anesthetics have been in regular use since the late 1800s. Most people currently get their exposure to them at the dentist office where novocaine also called lidocaine is injected prior to dental work. The onset and duration of action varies between different local anesthetics. Novocaine is one of the quickest onset and shortest acting local anesthetics. About 10 years ago surgeons began using longer acting bupivacaine applied via external pumps and tubes like the on-Q system to the operative site as a means of pain control after surgery.
The thought was that slow constant administration of a long acting local anesthetic to the operative site would allow for a quicker recovery after surgery, allow the patient to get up and around earlier and decrease the need for narcotic pain killers after surgery. Their use became especially popular with orthopedic surgeons who would place the catheters directly over bones or into joint spaces after surgery (such as knee or shoulder surgery) and to a lesser extent with general and thoracic surgeons. In 2007 it was discovered that prolonged exposure of joints to local anesthetic caused permanent loss of cartilage in the shoulder joint and multiple lawsuits have been filed since. Currently, there is no effective treatment for cartilage loss; patients who have experienced it have required additional diagnostic and therapeutic procedures and some required arthroplasty or shoulder replacement. Use among plastic surgeons was more limited and confined mostly to tummy tuck and breast surgery patients to decrease reliance on pain medications and allow for earlier ambulation after surgery. I tried this in the past on tummy tuck patients and was unimpressed by its ability to do either so I stopped doing it.

In October, 2011 the FDA approved Exparel which has just recently become available for public use. Exparel is long acting bupivacaine that has been placed in a container of microscopic fat cells. The anesthetic is then slowly released from the fat cell container into the body after injection. This extends the effectiveness of the anesthetic from a few hours up to 3 days. EXPAREL is the first and only multivesicular liposome-based local anesthetic that can be used around surgery in the same fashion as current local anesthetics. The medication is injected near the end of surgery and should not be injected with other local anesthetics at the same time as that could result in sudden release of all of the anesthetic from the fat cell containers. In clinical studies exparel was most effective in the first 24 hours after surgery. The fat cell containers can be damaged by contact with the liquid antiseptics commonly used just prior to surgery.

Due to the large surface areas involved in body contouring surgery like breast surgery and abdominoplasty I suspect this medication will prove most useful for rhinoplasty, facial implant, ear and hand surgery. Clinical studies have shown this medication to be most effective in the first 24 hours after surgery and to significantly reduce the need for narcotic pain medications after surgery.

I think we will see many more fat cell packaged medications in the future.

Obstruction to airflow in the lungs can be due to
fixed or irreversible lung disease (COPD)reversible (responsive to medications) obstruction due to heart failurereversible (responsive to medications) obstruction due to asthmaThe obstruction can be due to just one of the factors or any combination of 2 or more factors.

In asthma the walls of the breathing tubes into the lungs swell (become inflamed), muscles surrounding the tubes contract squeezing the tubes and then increased mucus secretions inside those tubes plugs them. This results in obstruction to airflow with audible wheezing and a tight feeling in the chest as the individual tries to get the air through narrowed plugged tubes. Attacks can be mild resolving quickly with medication or severe and life threatening.

Attacks of asthma can be stimulated or triggered by environmental factors like pollen, cigarette smoke, dust mites, pet hair, insect excretions, air pollution, stress, exercise, infections etc. The trigger can be something you are allergic to. The primary medications used to treat asthma are bronchodilators which counteract the muscle spasm and steroids which treat the inflammation.

For the asthmatic undergoing cosmetic surgery an attack can be triggered by irritation from the breathing tube in general anesthesia, dehydration associated with any surgery, inability to clear secretions while lying down under the influence of anesthesia or even pain medications used during surgery. The anesthesia staff needs to adjust the medications given in such situations and the patient needs to bring their inhaler with them to surgery, if they have one. If they patient smokes it is imperative that they not do so for at least one week prior to surgery. Cosmetic surgery in an asthmatic who was smoking within days of surgery is a dangerous combination as they are very sensitive to asthmatic triggers.

Abdominoplasty and belt lipectomy patients who are asthmatics are at higher risk of attacks because the immobility after surgery combined with greater pain medication needs.

The steroids used to treat inflammation in asthmatics also prolong the healing process so sutures may have to stay in longer than they otherwise would. The adverse affect on healing can be reversed by taking Vitamin A before and after surgery. The vitamin does not affect the anti-inflammatory effect so it will not exacerbate the asthma.

This is a tricky situation because even if normal lung function tests and a normal physical examination an asthmatic attack can occur due to any of the factors mentioned above. Furthermore, significant impairment of lung function can occur in asthmatics without symptoms. The history and general physical examination may not accurately indicate the severity of the asthma. The answer is not to just do the surgery under local because you think it would be safer. If you have an asthmatic attack induced by a cosmetic procedure and cannot have a breathing tube placed because of the spasm you will not survive. The answer is to do the surgery in an environment where should any of these problems arise the right personnel and equipment are present to handle the situation. Certified operating rooms will have the necessary oxygen, IV fluids, inhaled and injectable bronchodilators, oral and intravenous anti-inflammatory agents to treat an attack. It is highly unlikely that a non-certified operating room will have those medications.

Only asthmatics with stage I disease and an forced expiratory volume greater than 75% of predicted values can undergo surgery without a higher than normal risk of airway complications. Any asthmatic who has taken steroids, whether orally as a pill or as an inhaled medication, within 6 months of surgery needs perioperative steroids to cover for diminished adrenal function. Inhaled steroid medications may have to be temporarily replaced by oral prednisone until the patient has recovered from surgery. Any asthmatic with audible wheezing should not be having elective non-emergent surgery.

I am personally aware of a fit individual in his 30s who went to a martial arts practice session without his inhaler. He suddenly developed an exercise induced asthmatic attack. By the time the ambulance and paramedics had arrived he could not be revived and passed away. Prompt use of an inhaler would most likely have circumvented this. A similar situation could just have easily occurred with cosmetic surgery.

I was performing non-cosmetic reconstructive surgery on a healthy 20 year old patient in the hospital. He was asleep on the table and just as I was about to make the first cut the monitors showed the oxygen in his blood suddenly dropped to dangerously low levels. Anesthesia went into action and gave him a bronchodilator using an inhaler via the breathing tube. He rapidly responded and the oxygen came back to normal levels and was maintained there using intravenous medications. In a non-accredited operating room lacking all of the necessary equipment and medications that patient would have been in real deadly trouble. There is a good chance he would not have survived a liposuction procedure under local anesthesia in a non-certified operating room. Furthermore, that patient was previously thought to be healthy and had no previous history of asthma.

A Google search on "home laser" yielded 154,000,000 website links overseas and 48,000,000 when searched in the US. Most of the initial listings are for hair removal devices but there are also ones for treating acne and for facial rejuvenation and others treat skin conditions like psoriasis, vitiligo and dermatitis. Many of these home laser and light or ultrasonic devices can be purchased on the Internet. Sellers tout the benefits of these products in treating acne, age spots, large pores, wrinkles, sagging skin, puffy eyes, rosacea, cold sores, and many other skin conditions. However, few of the devices have been studied or approved by the Food and Drug Administration. Some of them sound sort of scary and could be a waste of money or at worst harmful. Sales of home cosmetic devices totaled $500 million last year, and are expected to nearly double to $950 million in 2015. Women have been removing hair from their legs for quite some time. Now it is a multibillion dollar per year industry.

These new home devices tend to fall into four categories:
Diode or intense pulsed light devices that target hair removal,Light-emitting diode (LED) or heat devices that claim benefits for acne treatmentRejuvenation devices to treat wrinkles using laser or infrared light Home phototherapy devices that provide UVB light.Home devices use lower fluences and longer pulse widths (lower power and less penetration), compared with office-based treatments.

Hair Removal Devices
To be effective, energy in the form of heat must be absorbed by the hair shaft, penetrate deep enough to affect the follicle or root of the hair, and be administered quickly enough to stop transference of the heat to skin surrounding the hair follicle and shaft. Since hair grows in cycles and is most sensitive to treatments during the active growth cycle, it takes several laser treatments to remove hair for good. All of the devices work best and are safest on dark hair in the presence of light skin color.

One of the first home laser devices to be studied was the Tria diode laser.

Studies showed average hair reductions of 60% at 1 month, 41% at 6 months, and 33% at 12 months after three home treatments in 77 appropriate users (Lasers Surg. Med. 2007;39:476-93). In another study 86 percent of patients experienced more than 30 percent hair reduction, and 38 percent had more than 80 percent hair reduction at one year after the last of 8 monthly treatments. Hair removal was complete for 31 percent, and of those who experienced regrowth, 69 percent reported that the hair was finer and lighter than before treatment. A skin color sensor blocks the device on darker skin colors otherwise these individuals will form skin blisters. The FDA approved the device for off-face use; it costs approximately $395.

The Silk’n SensEpil by Sephora uses intense pulsed light at low energy and short pulse durations. It also has a built-in Skin Color Sensor that locks the device on darker skin tones.
It is FDA approved for use on skin on or below the cheeks, it costs approximately $499 plus the price of disposable parts. Three studies in 34, 20, and 10 females, respectively, found it works best for thin hair on the legs and arms, and is less effective for hair in the armpit or groin areas (J. Cosmet. Laser Ther. 2009;11:106-9; Dermatol. Surg. 2009;35:483-9; and Lasers Surg. Med. 2010;42:287-91).

The No! No! Hair device uses patented Thermicon technology employing a thermal filament to deliver heat to the hair shaft without a light so they claim it is safe for all skin and hair colors.

It is the most heavily advertised hair removal device at least on late night television. In a study of 12 patients, twice-weekly treatment for 6 weeks with the low-energy device removed 44% of hair on the legs and 15% of hair in the bikini area at the 12-week follow-up (J. Drugs Dermatol. 2007;6:788-92).

In another study of 23 patients (7 men, 16 women) aged 18-55 years two sites on one leg of each patient were shaved 4 days before baseline, and then were treated every 3-4 days with the No! No! device on one site on the leg and by shaving the other site for 8 weeks. There was no significant difference between the 2 areas in terms of number of active hair follicles, hair regrowth, thickness or color after 1 month. That is to say singing the hair away with the device was no different than shaving it off. The No! No! device is basically an expensive razor.

The No! No! costs approximately $270.

Devices to Treat Acne
Eight studies since 1999 have shown that doctors' office treatments with blue light are effective in eliminating Propionibacterium acnes bacteria the causative agent of acne. Just clearing the bacteria isn’t enough a lot of the time because the bacteria produce irritating proteins that can be left behind so additional medical treatment with prescription or over the counter medications is frequently required. The Tria system comes with washes and topical creams, or patients can use the device with whatever prescription regimen they are on.

Four home devices now offer self-application of this blue light. The power density of the various devices makes a difference. Lower power density requires twice-weekly, 20-minute applications on each side of the face, which can be difficult for patients to do. Higher-density blue light devices, such as the Tria skin clarifying system, require less than 3 minutes twice a day.

The TRIA Skin Perfecting Blue Light uses blue light to kill bacteria in the pores thereby unclogging the pores and eliminating break outs.

Studies have showed 70% clearance of treated areas within 2 weeks. A company-sponsored study of the Tria device in 33 adults showed significant reductions in inflammatory acne lesions after 3 weeks of treatments (J. Drugs Dermatol. 2011;6:596-602). The device's blue light cartridge has to be replaced about every 2 months. The FDA approved the device for the treatment of acne, it costs approximately $245.

The No! No! Skin uses heat generated by light to treat acne. A green light releases oxygen from porphyrins produced by the bacteria to kill the bacteria. A red light diminishes pain and swelling.
It also costs about $270.

The Claro home device by Sephora
 combines heat and intense pulsed light:
-Blue Light (400-430nm): stimulates the production of oxygen, which attacks the bacteria that causes acne
- Red Light (600nm): combines with heat to soothe the inflammation, redness and soreness of each pimple while accelerating the healing process 
- Infra-Red Energy (700nm): creates heat that helps to kill the acne bacteria while increasing the effectiveness of blue light
It costs approximately $195 and comes in 3 colors - red, black and blue.

ThermaClear Acne Clearing Device delivers a 2-second pulse of targeted heat to each pimple to kill acne causing bacteria.
It's FDA cleared and advertised as safe and effective on all skin types and tones.

Zeno uses the combination of a topical medication containing 1% salicylic acid and skin moisturizer followed by the application of a small vibrating heat generating hand held device to treat acne.
At $40 it may be the cheapest device available.

Skin Wrinkle Removal - Rejuvenation
The PaloVia fractionated laser (Palomar Medical Technologies) was the first FDA-cleared at-home laser for treating wrinkles around the eyes.
There are two phases to the wrinkle treatment plan – the Initial Phase of one treatment per day for 30 days and the Maintenance Phase of one treatment 2 times per week. It costs about $500. A blinded study of 34 subjects presented at the 2010 meeting of the American Society for Laser Medicine and Surgery reported a 1-point improvement on the 9-point Fitzpatrick wrinkle scale in 90% of patients after 4 weeks of daily use and in 79% after 4 weeks of twice-weekly maintenance treatments.

Phototherapy

The Levia UVB device (Lerner Medical Devices) is approved for home use to treat psoriasis, vitiligo, and atopic dermatitis.
It directs concentrated ultraviolet B (UVB) light, which has a long history in treating psoriasis, to psoriasis plaques. The treatments require a prescription and programming of the device. Multiple studies have shown that home UVB therapy is as effective as office treatments.

I have not covered the scarier sounding devices in this blog. In conclusion I think we will see doctors doing laser hair removal as a thing of the past. It makes we wonder if the home laser tattoo removal kit is just around the corner.

Lupus is a rheumatic condition which affects the muscles, joints, and connective tissue. About 1.5 million people in the US have lupus which includes as many as 10,000 children. Nearly 90% of those diagnosed with lupus are female. It's an autoimmune disease. A healthy immune system produces special proteins or antibodies and these normally protect the body against bacteria and viruses that cause infections. In the case of lupus, the immune system confuses the body's healthy cells and sees them instead as if they were a bacteria or a virus, and the result is that our antibodies then attack some of our own body's healthy cells. You become allergic to yourself.

So, what causes lupus? The cause is unknown although genetic factors may be important. Certain things can trigger the disease such as infection, medications, and even extreme physical or emotional stress. There are different types of lupus; the commonest is something called systemic lupus erythematosus or SLE and this affects multiple organs, and there is also form known as discoid or cutaneous lupus which only affects the skin, and in as many as 10% of all lupus cases, they're classified as drug-induced lupus.

Systemic Lupus Erythematosus (SLE) is an autoimmune disease where self generated antibodies attack different organs systems in the body including blood vessels, liver, eyes, kidneys, joints, heart, heart valves, skin, lungs, brain...and/or form complexes with their protein targets (antigens) that damage these organ systems. The degree of damage to each organ system is highly variable. Arthritis and joint pain is the most frequent complaint. It is thought to be due to a genetic predisposition combined with viral infections. The disease can spontaneously remit, respond to corticosteroids or be unresponsive to available medications. 50% of those with SLE have some degree of heart and/or kidney involvement. Much of this organ damage can be masked and then suddenly become apparent especially during flare ups of the disease. I am aware of one women in her 30s who died in the recovery room after breast augmentation by another surgeon due to a heart attack caused by SLE induced damage to her coronary arteries.

So, what are the symptoms that are commonly associated with lupus? There are many. Classically, there will be butterfly rash. This is a rash that is across the cheeks and the bridge of the nose. There may be sensitivity to light that results in a rash. Also there can be ulcers in the nose or mouth, which are usually painless. There's a long list of many other symptoms that are associated with lupus including things like arthritis, inflammation of the lining around the organ such as the heart and the lungs, kidney problems. There may also be neurological disorders including problems with seizures or even psychosis. Blood problems and problems with the immune system are also found in lupus. And in addition to that, there are some nonspecific symptoms such as fever, weakness, fatigue, and weight loss. There is no known cure for lupus but the symptoms can be controlled with drugs, for example steroids, and sometimes more aggressive treatment is needed with immunosuppressive therapy.

Therefore it is imperative if you have systemic lupus that you have a complete examination of all major organ systems before undergoing any elective cosmetic surgery. This may include cardiac stress testing and blood tests for liver and kidney function. If you cannot be weaned off of prednisone that may be an ominous sign and may preclude any elective cosmetic surgery especially if any implants are involved.

If you are taking prednisone for lupus the medication can also prolong the healing time after surgery and weaken your ability to fight infection so proceed with caution before undergoing any elective cosmetic surgery.

For detailed information, support groups and to live the fullest life that you can with lupus visit the Lupus Foundation of America and the Lupus Research Institute.

In a survey released today by the American Academy of Cosmetic Surgery (AACS), 71% of respondents think society is less judgmental about cosmetic surgery than it was just five years ago. Furthermore, about 62% said society’s attitude toward cosmetic surgery made them feel more comfortable about getting a cosmetic medical procedure at a skin clinic or medical spa.

“This is a confirmation of what many of us have felt for a long time; that cosmetic surgery has become mainstream,” said Dr. Mark Berman, AACS president-elect. “A variety of factors have contributed to the normalization of our industry, but the bottom line is that people are not afraid to talk openly about cosmetic surgery anymore.”

According to the survey, the most accepted invasive procedures are breast augmentation (42.4%), face lift (32.2%) and tummy tuck (32.1%). Among noninvasive procedures, the most accepted are laser hair removal (61.9%) and Botox (61.6%). Additionally, 52% of respondents said they would tell family about having invasive cosmetic surgery.

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How Come Fractional CO2 Aesthetic Lasers Are Now The Top Fractional Procedure For Skin-Tightening?

CO2 laser skin resurfacing is not really a new principle. Co2 laser resurfacing has been around for 25 years. While conventional laser ablation had been fantastic for facial lines and wrinkles, scarring, sun damage or elastosis, there were substantive threat of infections, scarring and pigmentary differences. All those negative effects made this complete ablation to drop in favor with laser surgeons and subjects as well.

The concept of fractional laser treatments has been around since 04. Basically, fractional treatments provides for a small fraction of the epidermis is treated even though the all of the intervening areas are not ablated. These untouched areas of dermis all around the treated zones provides for swift healing.

As this methods was combined with with a CO2 laser, exhilaration within the laser clinic community catapulted. There are specific reasons for the medical spa community’s excitement:

First, there’s a smaller amount of downtime.

Conventional full laser ablation methods took extended down times of as many as 6 weeks. A handful of clients might have erythema (redness) for nearly eight months. By using Fraxel remedies, the down-time is from 3 to 6 days depending on the energy levels used. Such fast recuperation gives a much higher degree of expediency for your usual individual.

2. Much less danger of secondary complications.

Utilizing old-school total ablation laser procedures the chance of contamination, scarring like hypertrophic scarring and color alterations like hypopigmentation were much more frequent even with the most practiced laser surgeons. Considering the fact that Fraxel CO2 solutions leaves behind the majority of the dermis intact, the pitfalls linked with the approach are reduced.

3. Improvement.

Though much less of a dramatic end result when compared to old school CO2 laser solutions, the lowered risk and fine effects help make newer fractional laser treatments an alluring laser. In contrast to non-ablative fractional lasers, fractional CO2 lasers allow for significantly greater skin tightening. Fractional CO2 laser treatments are frequently performed again too. For scarring damage, it ordinarily involves 3 procedures in order to lessen the the scars. There are several fraxel CO2 lasers that you can purchase:

1. Smart Skin by Cynosure. This particular laser goes to thirty W in a two millisecond length. There are plenty of various parameters which may be selected so the procedure is personalized to every single customer.

2. Active FX & Deep FX by Lumenis: This fractional skin is also well-known, having said that you will find a couple of spot sizes which end up being switched out through a procedure.

3. Fraxel Repair from Solta: This laser skin penetrates really deeply. Be certain you look at a seasoned MD, since the highest rate of problems have been involved with this particular laser do to the level of penetration.

4. eCO by Lutronics. This fractionated laser is certainly attaining footing inside quite a few skin clinics and has a chaos technology which is good.

Those might be all the main fractional CO2 lasers which are typically though of as lasers which are generally easy to apply and show results. Certainly, there are different lasers, yet, some can be low powered and / or studies are lacking.

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Gone are the days when plastic surgery was simply for the rich and famous and something you felt the need to sweep under the rug.

These days, it is popular and even hip to have something ‘done’. Women and men get it done for all sorts of purposes – to help feel great about themselves, to get rid of some type of medical issue, or just to shed pounds efficiently.

What ever the reason, it is fundamental that you take on simple protection measures since even though it’s cosmetic, the dangers will not be. So before you consent to change the way you look, here is what precisely you want to do:

Chose a capable surgeon: The most critical concern in plastic surgery is not the cost; it’s actually precisely how experienced your surgeon is. You’re doing this since you aspire to try to improve your physical appearance, and it is solely having a respectable and established physician that are you able to be sure that the outcomes are as predicted. So even should you are required to fork out a lot more, choose a cosmetic surgeon who is trained and qualified to do plastic surgery as well as someone that is experienced in the particular treatment that you’re keen on.

Insist on a safe setting: Cosmetic surgery is just like every other surgical treatment in that you’ll be under the effects of anesthesia and you’ll go through blood loss. Therefore, just in case anything goes completely wrong, it is ideal to have surgical treatments conducted in a clinic in which crisis care can be found at a 24×7 basis. If your surgery is actually slated at a private aesthetic surgical clinic, find out about medical facilities which might be in the area and where you might receive emergency care if needed.

Learn recommendations: And finally, it’s very important to stay within your physician’s recommendations ahead of as well as after the surgery. You might have to stop smoking and/or go off particular drugs (if you are on medicines). Also, after the treatment is done, you could be in a good amount of discomfort, but talk with your medical professional before you decide to commence swallowing painkillers all on your own. It may perhaps be some time before you start seeing results, primarily with liposuctions and alternative surgeries performed on the facial area, which means you need to be patient. It’s also possible to have to undergo physiotherapy in some cases, so consult your doctor to be able to provide you all the info prior to deciding to sign on the dotted line.

It could be aesthetic, nevertheless the hazards exist because it is surgery in the end. But should you consider the basic safety measures plus follow directions, there is very little need to dread cosmetic surgery.

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Exposing the Dangers of Cosmetic Fillers Bought Online

Plastic surgeons routinely use dermal, or cosmetic fillers, to smooth the effects of wrinkles and aging on the skin of the face and neck. Usually, these cosmetic fillers are injected into a specific area of the face with a syringe. Whereas in the United States dermal fillers are classified as medication and require a prescription, in the UK, they are classified only as a medical device, which means that they are quite easy for anyone to obtain. Many of these products are being sold over the internet, where it is difficult to trace exactly where the products are coming from and who is selling them.

Unregulated Substances

The British Association of Aesthetic Plastic Surgeons (BAAPS) recently issued a warning against the use of these cosmetic fillers purchased online. BAAPS warns that DIY cosmetic fillers are dangerous because of the unknown and unregulated substances they contain. There is a danger that the substances are not what they claim to be or that they are improperly diluted, which can also result in life threatening complications for the user.

Risk of Facial Paralysis

In addition, the degree of skill and the knowledge of human anatomy that are required to properly inject the fillers make them unsuitable for home use. Plastic surgeons spend years learning about facial anatomy and learning how to properly inject cosmetic fillers. The human face is very complex, and the correct place to inject a dermal filler may be only millimeters away from a place that could cause permanent damage. In the US, one death has even been reported from the use of these cosmetic filler kits.

Professional Clinics are Much Safer

People are putting themselves at great risk by purchasing online cosmetic fillers and undergoing what is essentially home cosmetic surgery – but without the presence of a surgeon. The dangers of permanent disfigurement and paralysis of the facial muscles or even death are much greater than the risks associated with having these procedures done professionally.

The conclusion is that it is much safer to work with an experienced UK plastic surgery clinic, such as Transform, the UK’s largest plastic surgery clinic for more than 30 years. Professionals advise against performing such dangerous experiments at home. In addition, going to a clinic also dramatically reduces the risk of complications resulting from this type of procedure. In the interest of public safety, BAAPS is also calling for more extensive regulation of these cosmetic surgery related products in the UK.

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