The annual Komen for the Cure 5K race is coming up soon on May 12th. Don’t be left out. Click on the link below and join Team Wigod Plastic Surgery for the Race. We will have runners as well as walkers. Sign up in time and get a highly prized Team Wigod Pink Bandanna.
Why join the Race? To help raise money for a very effective charity in the fight against breast cancer. 75% of the money raised stays local to fund screening and education, with a particular emphasis on low income and geographically isolated women. Komen Boise just released 2012 grants to 21 recipients totaling $220,000. That is in addition to $80,000 earlier this year. The Boise organization also just united with the Coer d’Alene group to form Komen Idaho. The service area will be expanded from 19 to 28 counties. Fundraising is down this year relative to last year, so please help meet this greater need.
Komen Boise produced some great videos to illustrate the cause. Take a look and pass the link along to a friend.
Race for the Cure Boise: Susan G. Komen Boise and Marie Edwards http://youtu.be/oN2TVkDFNks This is the inspirational story of a breast cancer patient who decided to share her story. Thanks to Susan G. Komen Boise, Marie Edwards wants everyone to know there are no more excuses for not getting a mammogram. Awareness of breast cancer isn’t enough. We need action. Please donate and participate in the Race for the Cure on Saturday May 12 in Boise, Idaho.
Race for the Cure Boise: Komen Boise, St. Luke’s and Women’s Health Check http://youtu.be/gouv7XSc_yo The state of Idaho ranks 51st in the nation in mammogram screening rates. Let’s do better. Susan G. Komen Boise is proud to partner with many local organizations like St. Luke’s and Women’s Health Check to provide direct assistance to women and families affected by breast cancer. Please donate and participate in the Race for the Cure on Saturday May 12 in Boise, Idaho.
Race for the Cure Boise: Komen Boise, Saint Alphonsus and Terry Reilly http://youtu.be/osrhT9mrz9M Susan G. Komen Boise is proud to partner with many local organizations like Saint Alphonsus and Terry Reilly Health Services to provide direct assistance to women and families affected by breast cancer. Last year, Komen Boise and its partners made 1,800 mammograms possible. Please donate and participate in the Race for the Cure on Saturday May 12 in Boise, Idaho.
Race for the Cure Boise: Komen Boise, Saint Alphonsus and American Cancer Society http://youtu.be/_SIkX8PwBnI Susan G. Komen Boise is proud to partner with many local organizations like Saint Alphonsus and the American Cancer Society to provide direct assistance to women and families affected by breast cancer. Seventy-five percent of the funds that Komen Boise raises locally, stay local. Thank you for making an impact. Please donate and participate in the Race for the Cure on Saturday May 12 in Boise, Idaho.
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Below are the transcripts for the most recent HealthSmart segments on KTVB. Go to our media page to see the videos. http://www.wigod.com/video-media.html
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I am a 23 year young male and I have acne. My father had cystic acne when he was a child that he had to get medically drained. I have been on doxycycline for almost 5 years now and thankfully have never had acne as severe as my father which I think I can thank my doxycycline for. My question is, when will my acne calm down to the point of where I no longer need to take medication? I still get a few pimples here and there even while on doxycycline, but my father is 52 and on no medication what so ever with getting a few pimples a year. So I assume that means that there is a point in time where the acne will calm down.
-Kevin
Dr. Wigod, what can Kevin as well as other viewers with adult acne expect in the future?
Acne is so common that it affects about 2 out of 3 people and about 1 in 5 will suffer from severe acne. Acne usually begins in puberty and is gone by the early 20’s, but may persist into later adulthood. By 45 years old, about 5% of men and women still have acne. So when will acne stop? Well, no one really knows. The good news is that patients with heavier and oilier skin that is more prone to acne tend to age better with fewer wrinkles and ultimately look younger.
What causes acne?
Sebaceous glands are found around hair follicles, under the skin at the base of the hair shafts. They make sebum which helps keep our skin smooth and moist so that we do not feel like a crocodile. In puberty, the cells that line the hair follicle shed more rapidly and in those with acne, these cells stick together more. This blocks the sebum. Add normal skin bacteria and you get the inflammation and pus that we call acne.
What can teens and adults do to help minimize their acne?
Diet, sun exposure, and stress do not seem to matter much. Heredity is what really matters. Wash your face twice a day gently with a 2% salicylic acid soap and do not squeeze the blemishes. Topical antimicrobial treatments like Benzoyl Peroxide or Clinidamycin gel and oral antibiotics may help reduce bacteria. Topical Retinoids, particularly Aldapalene, can be helpful in adults to reduce follicular cell blockage. They are related to Retin - A, so they have the nice side effect of helping to minimize wrinkles. Your primary care physician is a good place to start for help, but a Dermatologist should be seen for resistant cases requiring more aggressive treatment
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I have bags and wrinkled skin under my eyes that make me look old. How can surgery help and what are the risks?
There are three factors to consider when evaluating a patient for lower lid rejuvenation - skin quality, skin quantity, and fat distribution. Skin quality improvement is the most straightforward, but most frequently neglected and often least dramatic element of the three. All the things we advise for improved skin quality for other parts of the face - vitamin C products, peels, even laser - can be done for lower lid skin. The big thing to realize is that if skin is thin, discolored, or deeply wrinkled - crepe like we call it - surgery cannot improve its quality.
What about skin quantity, then?
The surgeon has to consider skin quality when deciding what type of operation to offer the patient, but he or she has to ignore it to determine if there is indeed excess skin. I think the easiest thing to do is just pinch gently and have the patient open and close the eyelid. The key factor with skin is to not remove too much. That can lead to disaster and is a whole different topic.
What about the bags under the eyes, then?
Lower eyelid anatomy is very complicated. There is fat around the eye to pad the globe against impact. As we age, the structures holding this fat in place weaken and the fat herniates and we see a bulge. The supporting structure’s connection to the bone, however, does not move much and then we get a groove, or tear trough which emphasizes the bulge. In lower lid surgery - blepharoplasty - this fat is located and manipulated. If there is excess fat, it can be trimmed, but you do not want to trim too much and make the patient look hollow or cadaverous - like someone starving. If the lower supporting attachments are released, the excess fat can be positioned lower instead of being completely removed and help minimize the groove. Fat can also be grafted into the groove, but this is very tricky.
Well, it all sounds very tricky. Next week we will discuss different types of lower lid blepharoplasty and potential complications to be avoided.
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Last week we discussed lower lid aging and how poor skin condition, skin excess, and fat excess all contribute to an aged look. Since creams and lasers can only do so much, what are the risks of surgery on such a delicate area?
Lower lids really are one of the trickiest aesthetic surgeries to perform safely and should only be performed by a plastic surgeon, facial plastic surgeon, or ophthalmic plastic surgeon with formal training. We worry about asymmetry, insufficient aesthetic improvement to satisfy the patient, and damage to the eye itself. Most problems, however, are caused by being too aggressive when trying to get a great result. You can end up with an ectropion.
Explain an ectropion.
When too much skin is removed from below the eyelashes or if the muscle in the area that allows you to squint is damaged, the eyelid is drawn down . The lower lid and eye globe become red and the patient has excessive tearing and a sad look. Not only does it look bad, it is also very uncomfortable. Try pulling your lower lid down for just a few moments. You start feeling dry almost immediately. This dryness can be debilitating and even lead to damage to the cornea eye covering with vision loss.
What can be done to avoid an ectropion?
When I go to meetings and see talks on lower lid surgery, it is usually not about how to get a better result, but about how to avoid problems like ectropion. One way is to do a canthoplasty. If you think of the lower lid as a wash line, the more clothes - or tension from removing skin - the lower it will be drawn down. If you tighten the wash line - or tighten the lower lid at the lateral canthus - you can fight those downward forces. Another way which I like is to approach the lid with incisions from the inside and remove as little skin as needed - called transconjunctival approach. I try to select my patients very carefully, counsel them about reasonable improvement, and make sure they know all the risks.
I recently attended the Northwest Society of Plastic Surgeons meeting and picked up lots of good ideas. Some were small points such as drain placement position and local anesthetic injection technique while others were larger concepts such as breast reduction and reconstruction approaches. These all come under the setting of building a better mousetrap and are very satisfying to most plastic surgeons in our attempt to perform the perfect operation. Really big ideas are usually seen at the major meetings like the American Society of Aesthetic of Plastic Surgeons in May. I will tell you what I find out in the June blog.
Below are the questions and answers for the last few HealthSmart segments. See the segments live every Tuesday Morning at 0735 on KTVB ch 28 or later on our Video and Media Web Page.
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Brow Lifts
“What types of fixation are available for endoscopic brow lifts and what are the advantages and disadvantages of those fixation methods?”
This is a pretty advanced question. First, we should discuss a few basics first. When we age, the brow droops and makes us look tired and angry. Our forehead muscle, or frontalis, elevates our brow to help keep our eyelids out of our eyes and caused forehead wrinkles. People see aging in the upper third of their face and think eyelids are the problem, but often, a droopy brow makes up 50% or more of the cause.
The question suggests that there is more than one way to lift a brow.
Yes, there are three main ways. Common to all of them is cutting the corrugator muscles, the ones we paralyze with Botox. Next, the brow is detatched from the superior orbital rim so that it is mobile and can be repositioned. There are 3 incisions: coronal, anterior hairline, and endoscopic. The coronal incision is the long one across the top and is used when there is significant brow droop, when the brow is asymmetric, and when there is a low hairline. It can cause numbness behind the incision line. The anterior hairline incision is used for the same reasons, except when the hairline is higher. I find in Boise, Idaho that this is the most common incision that I use. It is reliable, shortens the senile forehead, and the incision hides really very well.
And that brings us to the endoscopic lift and our question.
In an endoscopic lift, small incisions are and the operation is done via a video scope. It’s nice that there is less scar and numbness, but it is not as powerful of a lift. It is best used in younger or minimal lift patients, but is very popular in some markets. In the open lifts, a strip of scalp is removed and the lift is maintained by the tension of the closure. In the endoscopic, no skin it removed, so the lift is maintained by fixation. Fixation may be with a suture tied to a bone tunnel, a suture tied to a temporarily placed titanium screw that sticks out of your head for a few weeks, or with an endotine device. This is an absorbable plastic like device with is popped into a shallow hole drilled into the skull and holds the scalp up with multiple tines. I like it because it is relatively quick and easy, but it is expensive.
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Upper Lid Blephaproplasty
We previously discussed that a portion of upper face aging is due to brow droop. Let’s talk about how the other part, drooping upper lids.
Depending on the patient, upper lids may make up a large or small part of looking old. In most faces, upper lids are the feature which would benefit from surgery - or blepharoplasty - first. Extra skin that you can pinch is removed, as well as extra fat and muscle. In some patients, the operation can even be done under local anesthetic only and recovery is usually minimal. The scar hides nicely in the sulcus and usually is very hard to see.
It sounds simple, but we know by now, no operation ever is. What sorts of things are there to worry about.
Upper lid blepharoplasty is one of the most straight forward operation on the face, but there is a lot to be careful about. The upper lid is functional - it acts like a roll top desk to protect the eye. If you remove too much skin, the eye can become uncomfortably dry and even threaten vision. The levator muscle which acts like a window shade pulling up the lid can be damaged and potentially cause lid droop. Over resection of extra fat around the eye can make the orbit look hollow. Finally, bleeding caused behind the eye, while extremely rare, can cause vision loss.
So blepharoplasty while it seems simple, can be dangerous. What specialties have formal training for this procedure?
Plastic surgeons, ENT’s who have had facial plastic surgery training, and ophthalmologists - in particular those with ophthalmic plastic surgery training most frequently perform blepharoplasty. Even the most straight forward seeming operation can have problems. Some populations, such as asians and the elderly, can be especially challenging.
Does insurance ever cover upper lid blepharoplasty?
Overwhelmingly, most patient have aesthetic problems only, so it is a self pay procedure. In a small number, however, there is so much extra lid skin that patients actually cannot see well and have what we call a visual field deficit. If after exam by a surgeon, this is felt to be a possibility, the patient should be seen by an optometrist for visual field deficit testing. If it is indeed positive, the case can be submitted for insurance review.
Wigod Plastic Surgery - Plastic Surgery for Boise, Meridian, and the greater Southeastern Idaho Region
Below are the questions and answers for last month’s Health Smart Segments presented on KTVB. Stop by our Video and Media page to see the videos and look for new videos every week.
FAT GRAFTING
What is fat grafting and how does it differ from stem cell grafting?
Transfer of fat from one body area to another. Adult stem cells make up a small portion and may account for increased graft survival. Stem cell grafting implies injected concentrated Stem cells, but is considered experimental. Those offering it outside of a University trial are either not really doing it or are using unproven and possibly ineffective or even dangerous methods.
What applications are there?
Breast augmentation and post mastectomy reconstruction, facial rejuvenation and reconstruction, body contour improvement (buttocks augmentation or liposuction defects).
How is it done?
Fat is gently liposuctioned from the abdomen, flanks, or thighs; separated by gravity or centrifuge, and reinjected into the breast, face, or body; not everyone is a candidate, there are variable take rates to redo injections should be expected, and for breast augmentation is still controversial.
EARLY FACIAL AGING
A study in the January issue of the American Society of Plastic Surgeons suggested that patients who had facelifts at a younger age had better results and satisfaction rates. In recent years, however, we have heard so much about using less invasive methods such as Botox, fillers, and lasers for facial aging. How does the patient who looks in the mirror and sees early signs of aging make sense of all the confusing information out there?
Facial aging, like anything else, is a diagnosis. Early signs of aging include skin quality changes, volume loss, and drooping tissue. To get a coordinated treatment plan, see a plastic surgeon.
What would a typical plan for a patient with early aging sound like?
The first step is minimizing sun exposure and ceasing smoking if you are a smoker. Next is life long skin care. Dermatologists and Plastic surgeons can recommend medical grade products to optimally treat skin problems such as loss of elasticity and pigment changes. I particularly like vitamin c, hydroquinone, and sun screen products. Surface treatments like microdermabrasion are also helpful.
Okay, what if the patient is willing to be a little more aggressive?
That is when I would discuss injectables. Botox is good for easing wrinkle lines around the forehead, eyes, and mouth. Injectable fillers like Juvederm and Restylane are good for filling nasolabial hollows and marionette line. Injectables can work well for patients in their 30’s, 40’s and sometimes even 50’s, but may be overused by practitioners who cannot offer surgical options. All these treatments do not cost as much as surgery and do not have the same risks, but do not have the long lasting and potentially dramatic results.
What about the early aging patient who is willing to spend more and take more risk?
That is the debate that the article is addressing. Medical lasers are well proven to help with hair reduction and skin pigment problems, but there is no magic bullet yet that reliably tightens skin and the deeper structures. Laser and other advanced technologies have been touted to be great ways to selectively heat and shrink aged skin, but have overall disappointing results. These treatments are expensive, may or may not have the promised effect, and that effect may not be long lasting. I tell patients that if they are not ready for a surgery, have several thousand dollars burning a hole in their pocket, and would accept the risk of little to no improvement, the newer tightening treatments are reasonable to try.
What about this recent study which suggests that if a patient does choose surgery for early aging, he or she may have better results than waiting later.
The study authors think that patients with early indications for surgery may have higher quality tissue for repair and therefore have better and more reliable long term results than using non invasive methods early and doing surgery later. The surgery studied, however, is not a minimal approach. The SMAS layer of the face was tightened and this should only be done by an well trained plastic surgeon. Younger patient who have signs of aging should therefore feel more confident in choosing surgery as long as they can accept the risks and costs as well as possible secondary surgery when they are older.
ADOLESCENT PLASTIC SURGERY
A paper in the January issue of the journal Plastic and Reconstructive Surgery examines cosmetic surgery in the adolescent patient. Dr. Wigod, tell us how common is adolescent cosmetic surgery?
Overall, adolescents make up 2% of cosmetic surgery patients. I would say that I see about that percentage here in Boise. Approximately 1/3 of those surgeries were for prominent ears (otoplasty), 1/4 for nose surgery (rhinoplasty), 1/8 for breast reduction, and 1/8 for breast augmentation.
How are these patients different than adult ones?
We have to consider both anatomic and emotional maturity when evaluating younger patients for surgery. Anatomic maturity can vary greatly, but ears are about 80% formed by 7 or 8, noses by 13 to 16, and breasts by 16 years old.
What about emotional maturity?
The most important qualification is emotional maturity. Body image is the subjective perception of the body as it is seen through the mind’s eye. It is considered reasonably well formed in teenagers such that it can respond favorably to a surgery. The request for surgery must originate from the patient and reflect internal motivation - “I will feel more confident” or “I will be happier with my photos” as opposed to “I will be more romantically appealing” or “people will like me more and tease me less.”
So, when is the right time for an adolescent to have surgery?
Assuming anatomic and emotional maturity, breast and nose surgery is reasonably done around 16 years old. Breast reductions, both female and male, can really improve an adolescent’s quality of life. Breast augmentations, however, are little different. The American Society of Plastic Surgeons recommends that patients be at least 18 years old, unless it is to treat a birth deformity. Rhinoplasty might be timed over a long break so that the changes have healed and are less easily noticed - it’s hard to hide your face.
SILICONE GEL BREAST IMPLANT SAFEFY
Recently, silicone gel implants have been back in the news. French implant maker PIP was shut down amid accusations of using cheaper industrial grade silicone in there implants and having rupture rate double the industry average. Dr. Wigod, how does this news affect women in the United States?
American women have nothing to fear in this instance. About 20% of PIP implants were used in France and the rest were exported to Britain, Spain, and Latin America. None were sold in the United States, thanks to more stringent testing requirements of the FDA.
What implants are available in this country and are they safe?
There are only two companies approved for silicone implant manufacture, Allergan and Mentor. Silicone was taken off the market in 1992 because its safety profile was never established. After careful scientific study, silicone was proven to be unrelated to autoimmune disorders as well as a various other illnesses. These two companies then formulated new products that caused fewer local healing problems and had easier clean up if they did rupture.
How are the new implants different?
New implants have been released since 2006. They are less liquid, or more cohesive, so they hold together better, but sill feel soft. In fact, if you cut one in half, it does not go anywhere. The FDA use to recommend that patients have an MRI every 2 years to detect leaks, but that was rescinded, so I have been more likely to recommend silicone because it feels better and ripples less than saline.
SURGERY FOR MORBID OBESITY
About one third of U.S. adults are considered obese. Idaho’s obesity rate ranks a relatively good 32nd in the nation, but still one quarter of our population significantly overweight. Dr. Wigod, how do doctors determine who is obese and how does it impact their health?
In medicine, we like measurements and clear definitions. Body Mass Index, or BMI, is a calculation of weight divided by height squared. So the heavier you are, the higher your BMI. You can find BMI calculators on the internet. BMI greater than 25 is considered overweight and greater than 30 is considered obese. Obesity is associated with increased rates of heart disease, stroke, diabetes, certain cancers, and increased surgical complications, so it is a real public health problem.
Most of us think of diet and exercise to decrease our weight. How can surgery be helpful?
When people reach a BMI greater than 40, they are classified as being morbidly obese. They are at least 100 pounds over their ideal body weight and often suffer from arthritis, sleep apnea, heart burn, hypertension, and even heart and lung failure. In these patients, traditional medical weight loss approaches are frequently unsuccessful. Operations on the stomach and bowels created and performed by general surgeons may effectively assist with significant weight loss. Once the weight is lost, then Plastic Surgery is done to remove excess skin if necessary.
What operations are available and will insurance cover their cost?
One approach is the Roux-en-Y Gastric Bypass. The stomach is shrunk by surgically stapling it off and drainage from the rest of the stomach is diverted downstream. This operation offers effective and rapid weight loss, but may have complication like bowel leakage, obstruction, and malnutrition. Another operation is Laparoscopic Adjustable Grastric Banding, or Lap-Band. In this approach, an externally adjustable synthetic band is placed around the entrance to the stomach to reduce its effective capacity. No re-routing of the intestines is required, but the procedure still has problems and weight loss may not be as effective. It is a complicated debate that should be presented by a massive weight loss general surgeon during an individual consultation. Both St. Alphonsus and St. Luke’s have well established surgical weight loss programs with expert surgeons. For qualified patients, insurance may cover the procedure.
Wigod Plastic Surgery - Plastic Surgery for Boise, Meridian, and the greater Southeastern Idaho Region
Holiday Party Fun - yes, the woman pointing her tongue is Mrs. Wigod
I continue to answer Plastic Surgery questions every Tuesday morning on KTVB. I have tried to shape each segment into a mini consultation to educate viewers about deceptively complex cosmetic and reconstructive issues. The station has allowed the videos to be placed on my web site under the new page “Video and Media.” Unless there is something particularly timely and important, I will use the Web Log to summarize the segments presented in the previous month.
The first topic was Breast Reduction, one of Plastic Surgery’s highest patient satisfaction operations.
The second topic was Doctor Consultation Questionnaire. There are some important questions to ask before, during, and after your plastic surgery consultation.
The third topic was Fat Grafting, its applications, and how it is different from stem cell grafting.
The fourth topic was an approach to Early Facial Aging and how surgery may be a better option than fillers, Botox, and lasers in certain patients less than 50.
After listening to news radio on the daily commute, the world can seem like a pretty depressing place. I only have to think for a moment, however, to remember how much I have to be thankful for. Below is my partial list. Many I know have had a tough year, but I hope all of you have something to be thankful for as well.
I am thankful for my wife who manages both home and office allows me to practice surgery without guilt.
I am thankful for children so that my errors may be their wisdom.
I am thankful for my parents who gave me every opportunity.
I am thankful for my patients who have given me their confidence and understanding.
I am thankful for my fellow Boise Plastic Surgeons who are collegial professionals.
I am thankful for my referring physicians who have trusted me to care for their patients.
I am thankful for the best office staff that I have ever had.
I am thankful for hospital administration and staff who have facilitated my practice.
I am thankful to practice in a field where patients actually want to go to the doctor.
I am thankful that I get to do arts and crafts everyday and call it work.
I am thankful for my patients’ reminder that we cannot take our health for granted and should appreciate every day.
After graduating medical school, Dr. Wigod completed eight years of formal General Surgery Residency and Plastic Surgery Fellowship training. His 16 years of higher education allows him to perform both Cosmetic and Reconstructive Plastic Surgery and to treat the whole patient without being limited to one body part or technique. Broad surgical training, large volume practice experience, and continuing education assist Dr. Wigod in his efforts to provide optimal care for his patients. Dr. Wigod has experience in all aspects of Plastic Surgery, but now specializes in Cosmetic Surgery of the Breast, Body and Face, as well as Breast Cancer Reconstruction.
After graduating medical school, Dr. Wigod completed eight years of formal General Surgery Residency and Plastic Surgery Fellowship training. His 16 years of higher education allows him to perform both Cosmetic and Reconstructive Plastic Surgery and to treat the whole patient without being limited to one body part or technique. Broad surgical training, large volume practice experience, and continuing education assist Dr. Wigod in his efforts to provide optimal care for his patients. Dr. Wigod has experience in all aspects of Plastic Surgery, but now specializes in Cosmetic Surgery of the Breast, Body and Face, as well as Breast Cancer Reconstruction.
