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FIFA Women’s World Cup and Facial Injuries

Because the FIFA Women’s World Cup has ended, a reminder of the risk for serious facial injuries in soccer players is warranted. Many of the saw the exciting World Cup soccer championships in Canada this past month. We also saw the physical nature of the game as well as many sports-related injuries to the face and head. Who can forget the American player who suffered a head injury and was nearly knocked unconscious. Specifically, for plastic surgeons, a new Brazilian study highlights the severity of soccer-related facial fractures requiring surgery. Dr. Charles Goldenberg, MD, PhD, of University of São Paulo and colleagues write, "Due to exposure and the lack of protection for the face, the occasional maxillofacial trauma sustained during soccer games often entails serious facial injuries requiring hospital admissions and invasive procedures." The researchers assembled data on 45 patients undergoing surgical treatment for soccer-related facial fractures at two large university hospital centers in São Paulo between 2000 and 2013. The 45 soccer injuries accounted for two percent of surgically treated facial fractures during that time. Forty-four of the patients were male; the average age was 28 years. All of the injured players were amateurs. The nose and upper jaw (maxilla) accounted for 35 percent of fractures and the cheekbone (zygomatic bone) for another 35 percent. Most of the remaining fractures were of the lower jaw (mandible) and eye socket (orbit). Eighty-seven percent of the injuries were caused by collision with another player; the rest occurred when the player was struck by the ball. Nasal fractures were treated by repositioning (reducing) the fractured bones to their proper place and splinting until they healed. Other types of facial fractures required open surgery and internal fixation (plates, screws) to reposition the bones. The patients remained in the hospital for about five days on average, and were told they could return to play after six to eight weeks of healing. The results are consistent with previous studies of soccer-related facial injuries. Lower extremity injuries (leg and foot) are much more common, fractures and other injuries to the head and face are a significant risk. The researchers highlight the need for careful examination of the nasal cavity to look for possible septal hematomas (blood collections), which could lead to serious complications. The online, open-access article is accompanied by videos illustrating the authors' approach to diagnosis and management of septal hematomas and the potential consequences of untreated nasal fracture.

Will insurance cover my breast reduction?

This is a question which comes up alot! For breast reduction procedures to be covered by insurance you have to fulfill certain criteria: First you need to have symptoms related to large breasts (macromastia) such as neck pain, shoulder strap grooving, upper or lower back pain and/or rash underneath your breasts, etc. The second criteria for most carriers is that need to fit within a sliding scale. This means that depending on your height and weight, you need to have a certain amount of breast tissue removed from each breast to qualify for insurance coverage. For example Blue Cross uses the Schnur Sliding which I linked. Let me run through an example. Let say a woman is 5'5" and weighs 150 lbs. Her body surface area (BSA) is 1.77. Under this Schnur scale,a surgeon would have to remove at least 425gm (about a pound) of tissue from each breast. This might be just right or too much for a woman who may otherwise qualify for a breast reduction or breast lift. Most plastic surgeons believe that these sliding scales do not correlate with overall benefit of breast reduction surgery. It can be very frustrating to both patients and plastic surgeons because a lot more women would benefit from this surgery than the insurance companies allow. Nonetheless, please make an appointment with a board certified plastic surgeon who can completely evaluate you before deciding the correct course.

Plastic surgery for ethnic patients

In 2010, over 3. 2 million cosmetic plastic surgery procedures were performed on that the patients. This is an increase of 243% when compared to 2000. Plastic surgery is becoming more common and mainstreamed and therefore, ethnic are becoming more aware of their options. This mainstreaming has removed the stigma that once may have been associated with plastic surgery. Medical technology improvements and reduce cost have also contributed to the rise in demand. Ethnic patients who have plastic surgery have similar motivation as other patients. The majority of patients want to maintain their ethnicity. They do not want to lose the important facial features that exhibit racial character, But rather want to reduce the signs of aging, look refreshed and rejuvenated or refined to create balance and symmetry of her body and/or face. Some of the most commonly requested surgeries by ethnic patients are liposuction, breast reduction and Botox.

Acellular dermal matrix helpful in breast reconstruction, revision surgery.

Breast cancer patients undergoing mastectomy can be treated with in the reconstruction using implants. The type of material called acellular dermal matrix or,ADM, can be used to improve the quality of reconstruction. In a recent study, in the January issue of Plastic and Reconstructive Surgery, the official Journal of the American Society of Plastic Surgery, the importance of ADM was highlighted in those patients requiring revision surgery. After breast reconstruction. In this particular study, over a five-year period, ADM was used as a part of revision surgery in a total of the 135 breast reconstruction procedures. The ADM we used correct the underlying fold of the breast and to provide support and lower pole of the breast. It was also used to manage hardening (contracture) of the capsule around the breast implants. Less commonly, ADM was used to manage problems related to incorrect positioning or rippling. The overall success rate was 95.5% with the complication rate of just 5%. Further surgery was only needed, in about 1% of cases. This was much lower than expected. The study confirms that ADM is here to stay in breast reconstruction and breast revision surgery.

CDC Warning on Plastic Surgery Performed in Dominican Republic

The Division of Global Migration and Quarantine and the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control (CDC) are investigating cases of surgical-site infections caused by rapidly growing Mycobacterial species (e.g. M. abscessus and M. chelonae) following plastic surgery in the Dominican Republic. Fifteen cases – all resulting from procedures performed in the Dominican Republic – have been identified in five states, prompting several state and local health departments in the northeast United States to issue an advisory for health-care providers to be aware of the condition, and to notify their local health department in the event they should identify or suspect a case. “Though the cases so far appear to have been identified only in the northeast, it’s important for all ASPS members to be alert to the potential of this infection,” says ASPS President Robert X. Murphy Jr., MD. “Ease of travel has turned medical tourism into a booming industry. Unfortunately, people often don’t think of the downside of medical tourism – you’re not guaranteed the same quality of safety measures that exist in this country, and should you have problems after you return, your surgeon is not there to take care of you.” The advisory is aimed at all plastic surgery; dermatology; primary care; family, emergency and internal medicine; general surgery; infectious disease; laboratory medicine (including Mycobacteriology laboratory and staff) and infection control staff. The American Society of Plastic Surgeons is now collaborating with the CDC, in order to effectively disseminate this information to the ASPS membership. “These surgical-site infections represent a serious public health problem affecting patients who opt for low-cost cosmetic plastic surgery procedures overseas, in this case, the Dominican Republic,” says ASPS Patient Safety Committee Chair C. Bob Basu, MD, MPH. “Medical tourism may attract patients with ‘cheap deals,’ but unfortunately, these deals may compromise, or worse, completely ignore recognized quality and safety standards. “It underscores why it is vital for patients to choose a board-certified plastic surgeon who is an ASPS member,” he adds. “Our members only perform procedures in fully accredited facilities that ensure the highest standards for infection control and patient safety.“ Initial cases were reported by the Maryland Department of Health and Mental Hygiene in August 2013, with additional cases identified since then in Connecticut, Massachusetts, New York and Pennsylvania. All patients were women in the 18-50 age range who had undergone elective procedures that include abdominoplasty, mammaplasty and liposuction in the Dominican Republic from April through September in 2013. Symptoms have included abdominal abscess, pain, fever and wound discharge. No deaths have occurred. “At least nine of the case-patients had surgery at the same surgical center and were attended by the same surgeon,” notes Duc Nguyen of the CDC’s Prevention and Response branch of the DHQP, via e-mail. “Symptoms of infection developed after return to the United States; several patients consulted with plastic surgeons after their return who, in turn, notified their state and local health departments.” “Given that at least nine of the cases are arising from the same surgery center in the Dominican Republic,” adds Dr. Basu, “it raises deep concerns about the violation of sterilization procedures and the quality of the sterile products utilized.” Others who may have undergone surgical procedures in the Dominican Republic may be at risk for the “rapidly growing non-tuberculous mycobacterium” (RG-NTM) infections. “It is possible that additional infected patients have not yet been reported,” notes Nguyen. Healthcare providers should be aware of these cases and obtain cultures for mycobacterial culture from patients with cellulitis, soft tissue infection or cutaneous abscess who had a surgical procedure in the Dominican Republic after April 1, 2013. Physicians should notify their local health department if a case is identified.

Fat Grafting 101 cont’d

How does the harvest and preparation technique of affect outcomes? Harvest technique. Exposure to air a mechanical damage should be minimized during harvest. It is suggested that tissue harvest be performed using a 3– 4 mm blunt cannula or similar needle while utilizing minimal amounts of suction during extraction. Harvest sites. The primary concerns to be addressed during choice of harvest sites are adequate tissue volume and patient/physician preference. There is no compelling evidence regarding harvest site and efficacy of fat grafting. Graft preparation. Avoid contamination maximize tissue viability by minimizing exposure to air and mechanical damage. Injection technique. Graft injection should be performed using 2–2.5 mm blunt-tipped infusion cannula or similar blunt needle and with injection occurring in multiple passes, resulting in a small fat deposited with each pass. Injection site. Patient specific. There is no evidence to indicate whether or not injection site significantly effects graft viability. Use of epinephrine and lidocaine at the donor site. The use of either epinephrine or lidocaine has not been shown to affect graft viability. What risk factors need to be considered for patient selection at this level of invasiveness? No evidence was found and specifically addressed patient selection. Therefore, the recommendation was developed by consensus of the task force and is considered expert opinion. When determining whether or not a patient is an appropriate candidate for autologous fat grafting to the breasts, physician should exercise caution when considering high risk patients (those with risk factors for breast cancer: BRCA–1, BRCA–2, and/or personal or familial history of breast cancer with primary relatives). What advancements in research impacted current or future methods of autologous fat grafting? Current studies consist of both in vitro an animal studies describing manipulations to improve viability of the graft. No randomized control trials were identified. Further research needs to be done. Summary. Fat grafts may be considered for the use of breast that other sites, the specific techniques for grafting are not standardized. The results, therefore, may vary depending on the surgeon's technique and experience with the procedure. Although there are a few data to provide evidence for long-term safety and efficacy of fat grafting, the reported complications suggests that there are associated risks. Regarding fat grafting to the breast, there are no reports suggesting an increased risk of malignancy associated with fat grafting. Limited data available suggests the fact grafting not interfere with radiologic imaging and detecting breast cancer.

Fat Grafting 101

In 2009, the ASPS (American Society of Plastic Surgery) commissioned a task course regarding current applications and safety autologous fat grafts. A summary of the results helps both plastic surgeons and patient’s make an informed decision on whether this technique is appropriate. Here are some in the questions and answers addressed by the task force. What are the current and potential applications of autologous fat grafting? Fat grafting may be considered for breast augmentation and correction of defects associated with medical conditions and previous breast surgeries; however, results are dependent on technique and surgeon expertise. Because of the longevity of the graft is unknown, additional treatments may be necessary to obtain the desired effect. In addition, fluctuations in body weight can affect graft volume over time. What risks and complications are associated with fat grafting? Potential complications and risks are described below: 1. Anesthesia-related complications: These complications were uncommon in the review performed by the ASPS task force. 2. Infection. Cases of prolonged inflammation, staph infection, septic shock have been documented with these procedures. Most cases resolve with antibiotic therapy. 3. Bleeding. Cases of seroma or hematoma had been documented with these procedures. No cases, however of unusual or severe bleeding have been presented. 4. Less than expected beneficial outcome. Results from these procedures are typically reported as excellent or good. Overall graft volume loss, via reabsorption or necrosis, is the primary cause of poor results. Initial overcorrection, performed by an experienced surgeon can often compensate for this outcome. Instances of graft hypertrophy or overgrowth have been documented, but are rare. Other complications affecting aesthetic results include formation of calcified and noncalcified masses. 5. Interference with breast cancer detection. No evidence was found that strongly suggests that fat grafting to the breast interferes with the detection of breast cancer. 2 cases of breast cancer were reported after fat grafting to the breast, but there was no delay in detection or treatment. Radiologic studies suggest that imaging technologies (ultrasound, mammography and MRI) can identify the grafted fat tissue, microcalcifications and suspicious lesions; biopsies may be performed if an additional clarification is needed. 6. Embolism. The available literature documents a low case number of embolic complications including fat embolism, stroke, lipoid meningitis, septic shock, or phlebitis. Overall complications rate associated with fat grafting are not high. Cases of severe complications and death appeared to be extremely rare. Causation of these cases cannot be fully determined. No compelling evidence was found that would warrant a strong recommendation against autologous fat grafting. Fat grafting can be considered a safe method of augmentation and correction of defects associated with various medical conditions.

What is a tuberous breast? Constricted breast?

Tuberous breast deformity (or TBD) is a congenital deformity of the breast which can occur in both men and women. It is most likely apparent during puberty when the development of the breast compared. The exact etiology of this congenital abnormality is unclear, but it is thought to be of embryologic origin. Most reports suggest that the superficial investing fascia of the breast is abnormal and constricted at the base of the breast. This constriction at the base of the breast is responsible for the reduced width or base diameter. Fertility is not affected by this condition. Tuberous breast can also be referred to as a “constricted breast”, but tuberous is more descriptive. Tuberous breasts are not just a small breasts, rather atypically include abnormalities such as an enlarged, puffy (due to herniation of breast tissue) nipple areolar complex, a high breast fold (inframammary fold), unusually wide intermammary distance (increased sternal width), lack of breast tissue and a narrow base at the chest wall. There can be a wide range of these symptoms with some patients having very mild disease, and others having severe deformity. The condition can affect the ability of I woman to breast feed because of lack of development of the breast gland/breast ducts. If you suffer from tuberous breasts, contact Dr. Bermudez today for breast augmentation in San Francisco. He can provide an evaluation, and surgical correction for your breasts.

Blond or Brunette?

6 Scientific Differences between Blondes and Brunettes   Here are six little-known differences between blondes and brunettes, from the latest scientific literature: 1. On average, blondes take longer to get ready. A study conducted in 2009 (with over 3000 participants) found that blondes take 6 minutes longer than their darker-haired counterparts to get ready. Blondes will spend an average of 72 minutes a day on their beauty routine compared to 66 minutes for brunettes. 2. Natural blondes have more hair than natural brunettes. Natural blondes have approximately 120,000-147,000 hairs, while brunettes have 100,000-120,000. This makes perfect sense, as evolutionary biology tells us that hair evolved partially to protect the scalp from potentially damaging UV rays. As darker hair contains more of the pigment melanin, it naturally provides more of a protective barrier, and hence brunettes needed less hair to serve the same purpose. 3. A man’s preference in a woman’s hair color stems from his own hair color – and life experience. Although some reports state that Caucasian men generally prefer fair-haired women, an interesting review noted research that brunette men preferred brunette women; blonde men equally preferred blondes and brunettes; and blonde, brunette, and red-headed women all preferred dark-haired men. Furthermore, research has shown that both men and women are attracted to certain partners based on their intrapersonal interactions with others; that is, if you always had brown-haired friends growing up, but a blonde-haired bully picked on you constantly, you are more likely to stick to brown-haired partners later in life. This gets into a whole lot of psychological and sociological research that is outside of my realm 4. Blonde waitresses (restaurant servers) earn better tips. Despite their perceived level of overall attractiveness, blonde waitresses receive higher tips than darker-haired waitresses. In a 2009 survey of 482 waitresses conducted by Cornell University, blondes earned significant higher tips than their brunette counterparts, despite their reported levels of “sexiness”. What ever happened to 15% for standard service and 20% for good service for all? Hm. Moving on 5. Brunettes are perceived upon first meeting to be more intelligent. Research has shown that raters perceive women with dark hair to be more intelligent at a first meeting, The reason for the bias is unknown, but I speculate that it is due to the simple fact that women dye their hair blonde more than any other color. Not only does this mean that there are more blondes than brunettes after a certain age, but this also means that women who spend extra time focused on beauty and their appearance are more likely to be blonde. With that said, there are many incredibly smart blondes out there 6. When women dye their hair lighter, they feel more fun. True – when women dye their hair lighter, they have been proven to go out more (3 nights/week for blondes versus 2 for brunettes) and to feel more confident and youthful. Why this phenomenon exists is unknown. Part may be due to societal influences, as the majority of the Hollywood celebrities are blonde. Another theory is that many Caucasian women are born with hair that darkens with age, and so dyeing their hair reverts them to their youth. One additional possibility is that blonde hair is somewhat more forgiving of skin imperfections, which is why most women choose to lighten their hair as they get older. Although all of the aforementioned information is provided by scientific literature, the bottom line is that this article is just for fun. There are many beautiful and intelligent women who are both blonde and brunette. While each hair color may impart some of its own minor advantages upon a first meeting, the truth of the matter is that, over time, most of these perceived advantages will give way to the time-tested traits of its wearer, like excellent character, honesty, integrity and benevolence.

Father’s Day and Plastic Surgery?

A recent article in the New York Times highlights the increasing popularity of plastic surgery in men. The article suggests substituting the traditional Father's Day gifts for cosmetic treatment and surgery. Things like chin implants, botulinum toxin (Botox and dysport), facial fillers, liposuction, and other appearance improving treatments have rised in popularity not only over the last 10 years, but especially during Father's Day. It is no longer "taboo" for men to seek plastic surgery and this article highlights the fact that men generally are having more cosmetic procedures and treatments. According to the areas ASPS statistics, roughly 10% of all cosmetic procedures were performed in men in 2012 which is up from about 8% in 2010. Take a look at the article, it's very enjoyable and informative: http://bucks.blogs.nytimes.com/2013/06/10/happy-fathers-day-and-lose-those-love-handles/ Happy Father's Day!