Tag Archives: aging

Aesthetic Treatment Plan based on Facial Anatomy

Aesthetic injection of botox and fillers

Developing an Aesthetic Treatment Plan: Evaluating Facial Anatomy June 8, 2013.

Evaluating Facial Anatomy for Injectable Fillers and Botox

An fantastic discussion of evaluating facial anatomy, especially intrinsic aging of the facial bony structure, and fat pads. The injector in this discussion, Dr. Rebecca Fitzgerald, expert Dermatologist in Los Angeles is truly an artist and has a great ability to evaluate. I don’t entirely agree with everything, but I think that’s the artistry in our craft. But I finished the educational activity knowing that there’s much for me to learn and improve upon in my Botox and Juvederm aesthetic practice in Modesto, CA.

My main take home message: Fat Compartments of the Face

For me, a lot of what was discussed are things that I already do in my practice.  But I enjoyed listening to the topics of the fat compartments of the face.

Fat Compartments of the Face – Anatomy

The discussion here is supplemented with my own notes from:

Rohrich and Pessa, Plast. Reconstr. Surg. 119: 2219, 2007

  • Subcutaneous fat of the face is partitioned in distinct anatomical compartments
  • Nasolabial fold is a discrete unit with distinct anatomical boundaries
  • Malar fat pad is composed of three separate compartments: medial, middle, and lateral temporal cheek fat.
  • Orbital fat is located in three compartments determined by septal borders.
  • Facial aging is, in part, characterized by how these compartments change with age.

More Notes on Facial Anatomy.  There is much much more to facial anatomy than those very few pictures and descriptions on that webpage which I made a while ago.

Aesthetic Definitions

She talks about Hyaluronic Filler and Neuromodulators.  She uses these terms because they are non-specific, and doesn’t favor one manufacturer over another.

0.75 hours of CME credit earned from www.Medscape.com

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BRCA, Mastectomy, Angelina Jolie, and My Thoughts as a General Surgeon in Modesto, CA

I felt compelled to write a little bit on this subject.  I have been a breast cancer surgeon and have worked together with my wife, Dr. Tammy Wu on breast reconstruction after I had done the breast cancer operation.  In fact, part of my dream, which has somewhat died, was to create a breast cancer center.  The same kind that Angelina Jolie had gone to for her treatment.  It involves many breast cancer specialists under the same roof.

I had been one of the first surgeons in Modesto to bring sentinel lymph node technology to breast cancer surgeries.  I had helped certify my other surgical partners at a group which used to be called McHenry Medical Group.  We were a group of 6 surgeons at the time.  This was the group that brought me to Modesto, CA.  I also had been trained to perform skin sparing mastectomies.  Dr. Wu and I have performed several of these procedures together here in Modesto.  Dr. Wu would assist me in these procedures and then I would assist her in the reconstruction. However in 2006, we made a decision to move Surgical Artistry more toward a cosmetic surgery – only – focus.

Angelina Jolie’s surgery used sentinel lymph node technology, nipple sparing mastectomy techniques, and then followed up by breast reconstruction with tissue expanders and then with what I believe are anatomically shaped implants – possibly the implants that we have just been blogging about – the new gummy bear breast implants – approved in February of this year.  Dr. Wu has been familiar with all aspects of Angelina Jolie’s breast reconstruction with expanders and implants.

But what is new to me, as a general surgeon who backed off from breast cancer surgery in 2006 is: The nipple delay procedure – I think this is genius!.  This procedure is usually done when patients have had previous augmentation or when there is fear of cancer hiding underneath the nipple area, and also for improving nipple/areolar survival after mastectomies.  The blood supply is improved.  Dr. Tammy Wu explained to me that this idea is also done in plastic surgery procedures such as TRAM flaps – where a extraneous blood supply is cut off first and then a waiting period is done to have the rest of the blood supply improve – before performing the full surgery.  And I have never performed a double mastectomy.  I have received three requests (that I can remember) for this in my breast cancer surgery career, but I have turned all three of them down, but recognizing that it is a patient’s choice.  I have hooked them up with other surgeons.  I felt somewhat uncomfortable removing the mastectomies.  Not all of these patients has had definitive BRCA testing and at the time, and I would say that BRCA testing was newer back in the early 2000’s.  Thus some of these requests were based on just “disliking breast cancer” and wanting to “reduce breast cancer risk.”  But I know that breast cancer risk is present even after I do a mastecomy (meaning breast removal).  Why?  Because inevitably, I will leave some breast tissue behind, and much of the breast tissue left behind is in the nipple/areolar complex.  And even if I take the nipple/areolar complex (which is the standard mastectomy), I would leave some tissue and cells behind – especially on the skin flap.  If I made it too thin, the skin flap above could die.  Thus, I felt uncomfortable, personally, removing normal breasts – even though I knew I was married to someone who could reconstruct them very well.  So even if I removed them, the risk of cancer was still there.  Essentially I was thinking that I would reduce a woman’s general risk of breast cancer from 10% (this was the figure I used back then), down to about 5%.  It wasn’t worth it for me.  But with BRCA testing, it is a different story as you read below (the risk reduction is greater because you start at a higher number BRCA mutation positive risk – 87% per Angelina Jolie’s doctors).  So perhaps if I was practicing breast cancer surgeries today, I would be more “comfortable” with performing prophylactic double mastectomy (which is what Angelina Jolie received).

Angelina’s surgery – is public – as she wanted it, and in this blog I paraphrase highlights from Angelina’s general surgeon (breast surgeon).  I think it is wonderful that she is sharing and I think she made a good decision based on the knowledge that is available.

In Summary of Angelina’s surgery:

My one sentence summary of her recent breast surgeries from February 2013 to May 2013:

With a known BRCA1 genetic mutation, Angelina Jolie underwent a prophylactic nipple sparing double mastectomy with sentinel lymph node marking after passing a nipple delay surgery procedure, and then had a staged plastic surgery breast reconstruction procedure involving breast expanders and implants.

  • She underwent genetic testing.
  • She was diagnosed as being BRCA1 mutation positive.
  • She had her surgery done in California at a breast center / surgery center.
  • She had a technique done callled nipple delay.
  • She then underwent prophylactic double mastectomy with nipple sparing surgery
  • She had sentinel lymph node identification done, but not removed – this is in case she gets cancer in the area of her mastecomies in the future.
  • She had breast reconstruction with her plastic surgeon, first with expanders to stretch the skin envelope then with breast implants.

BRCA – a part of overall Breast Health

5/18/13

First, what does BRCA stand for?

BRCA stands for BReast CAncer susceptibility gene.  There are two of these genes identified #1 and #2.  thus the designation BRCA1 and BRCA2

What is BRCA?

  • BRCA1 and BRCA2 are tumor suppressor genes.
  • In normal cells, BRCA1 and BRCA2 help stabilize DNA and prevent uncontrolled cell growth.
  • Mutation of BRCA1 and BRCA2 has been linked to hereditary breast and ovarian cancer.
  • A woman’s risk over her lifetime of developing breast and/or ovarian cancer is much increased if she inherits a harmful mutation in BRCA1 or BRCA2.
  • the percentage of people in the general U.S. population that have any mutation in BRCA1 has been estimated to be between 0.1 – 0.6 percent.

Mutations of BRCA1 vs BRCA2

In addition to risk of breast and ovarian cancer BRCA1 and BRCA2 have additional cancer risks to other organs see list below.

BRCA1 mutations may have additional risk of these cancers

  • cervical
  • uterine
  • pancreatic
  • colon cancer

BRCA2 mutations may have additional risk of these cancers

  • pancreatic
  • stomach
  • gallbladder
  • bile duct
  • melanoma

 Angelina Jolie’s Mastectomy and her article in NY times.

  • She had a positive test for the BRCA1 mutation
  • She underwent double prophylactic mastectomy
  • Angelina Jolie’s Op-Ed contribution to the New York Times on May 14, 2013.
  • She explains that, she had a 87% risk of breast cancer and a 50% risk of ovarian cancer, according to her doctors.
  • Only a fraction of breast cancers have the BRCA1 gene mutation.
  • Those with the BRCA1 gene have a 65% risk of getting breast cancer on average.
  • On April 27, 2013 she finished three months of medical procedures which involved the mastectomies.
  • She chose to have bilateral prophylactic mastectomies, meaning removal of both breasts, preventative – without having the disease yet.
  • On Feb 2, 2013, she did a procedure known as “nipple delay” which rules out disease in the breast ducts behind the nipple and draws extra blood to the area.  It is a study which can increase the chances of saving the nipple.
  • 9 weeks later, she had mastectomy with implant reconstruction.
  • She says that her risk of developing breast cancer drops from 87% to under 5%.
  • A primary motivator for her surgery, she says, is so that her children don’t have to fear losing her to breast cancer.
  • The cost of testing for BRCA1 and BRCA2 is more than $3000 in the USA.
  • She chose not to keep her story private.

Angelina Jolie’s Surgeon, Dr. Kristi Funk Blogs on May 14, 2013:

  • Emphasizes that each woman’s case is different.  Surgery will not necessarily be the right choice for everyone.  The important thing is to be aware of your options.
  • Approximately 5-10% of all breast cancers and 14% of ovarian cancers occur from a BRCA1 or BRCA2 genetic mutation that is inherited from either parent.
  • Women carrying either a BRCA1 or BRCA2 mutation have up to a 87% lifetime chance of breast cacer and a 54% chance of Ovarian cancer.
  • General population (all comers), there is a 12% risk of breast cancer and less than 1% risk for ovarian cancer.
  • In the general population the risk for a BRCA mutation is 1-500 (.2%) people but those of Ashkenazi Jewish heritage it is 1 in 40.
  • In those who BRCA-1 carriers who get breast cancer, 85% will have a more aggressive “triple negative” subtype (vs. 15% of general population).  Triple negative breast cancers mean ER/PR negative and Her2 – normal.
  • 8 red flags that indication a possible BRCA mutation:
  1. 1st, 2nd, or 3rd degree relatives from mother or father, with breast cancer before age 50 or ovarian cancer at any age
  2. Ashenazi Jewish Heritage (Easter European)
  3. Male relative with breast cancer
  4. Any relative who is a known BRCA mutation carrier
  5. Breast cancer in self before age 50 – early onset.
  6. Two breast cancers in self, at any age
  7. “Triple negative” breast cancer in self.
  8. 2 or more family members with Breast, Ovarian, Pancreas, Prostate, Melanoma, Uterine, Colon, and Stomach Cancers.
  • There exists non-BRCA inherited genetic mutations associated with breast and ovarian cancer as well.
  • Feb 2, 2013, Angelina had her first operation, the nipple delay.
  • Feb 16, 2013, Mastectomy with Sentinel Nodes Identification – not removed – but dyed.
  • Her plastic surgeon was Dr. Jay Orringer, assisted by her breast cancer surgeon Dr. Kristi Funk – the writer of the blog which I’m paraphrasing from in this section.
  • April 27, 2013, 10 weeks after the mastectomies, she received reconstruction of the breasts with implants.

What is Nipple Delay Surgery?

  •  Considered when the nipple is thought to be at risk for either cancer disease or inadequate blood supply.
  • This is performed 1-2 weeks before the mastectomies.
  • The incision used is the planned mastecomy incision.
  • The small disc of tissue behind the nipple and areola is removed and sent for pathologic diagnosis – to rule out the presence of cancer.  If cancer is present in this area, then nipple sparing/areolar sparing mastecomy would be contraindicated.
  • This procedure could bring extra blood flow to the nipple aream lessening the chances of nipple and skin loss after nipple sparing/areolar sparing mastecomy.
  • This is similar to the delay procedure performed by plastic surgeons :  My wife says: “In Tram Flaps we cut off the inferior blood supply to the rectus muscle to allow the remaining blood supply to get used to taking over – this strengthens the remaining blood supply and in about 2 weeks the remainder of the surgery is done for breast reconstruction.”

How does this relate to us at Surgical Artistry?

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  • As a general surgeon, I (Calvin Lee, MD) am a breast cancer surgeon, and I have performed many breast cancer operations in the past including mastectomies.  In 2006, my practice changed and I focused less on breast cancer surgeries.  It is good for me to continue following trends and different thinking regarding breast cancer.
  • I was one of the first surgeons to bring Sentinel Lymph Node biopsy for breast cancer to Modesto, CA.  I helped certify the rest of the other surgeons whom I worked with (at the McHenry Medical Group) for this procedure, since this procedure was part of my residency.
  • I was one of the first to create an online support group for breast cancer.  It was founded in 1997.  And several national publications thought it was the most effective group on the internet at the time.  It is still active on the internet and has been since moved over to Yahoo for management and software run by Yahoo which is tons more stable than what I could have offered.  I also let members of the group run the breast cancer support group and I’ve stepped away for fear of malpractice issues of having a doctor be part of the group – patients there have their own doctors and I was afraid that they would start to look to me for answers and medicine as an art form is practice different and surgery/medicine should be very personalized as it had been for Angelina Jolie.
  • Dr. Wu and I have done several nipple sparing, areolar sparing, skin sparing breast mastectomies with implants together, along with sentinel lymph node biopsy.
  • A huge part of Dr. Tammy Wu’s practice is breast reconstruction after breast surgeries such as mastectomies.  She uses many different breast reconstruction techniques – including implants and expanders (as in Angelina Jolie’s case) or with the patients own tissue either from the back or from the abdomen.
  • We also use the anatomic teardrop shaped breast implants newly approved by the FDA.  I am not certain that these are the ones that Angelina Jolie received, but it is possible and Dr. Wu is the first surgeon in our area to be certified to use these implants.  There are choices other than the 410 Natrelles, there’s the Sientra shaped breast implants.

A great source of info:  Position paper by American Society of Breast Surgeons:

https://www.breastsurgeons.org/statements/PDF_Statements/BRCA_Testing.pdf updated September 2012.

  • The position statement on BRCA genetic testing for patients with and without breast cancer, above also talks about prophylactic oophorectomy (preventative ovary removal without the presence of cancer).
  • The American Society of Breast Surgeons say that patients without cancer but with a positive BRCA1 and/or BRCA2 deleterious mutation can achieve a greater than 90% reduction in breast cancer risk if they choose to have a bilateral prophylactic mastectomy (as Angelina Jolie did).

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What do we do at Surgical Artistry?

 

5 year patients choice     surgical artistry full page ad never boring

I get this question a good deal.  I think it’s probably somewhat confusing as to what we do and we offer a lot of procedures and products.  Basically we are a two surgeon medical group offering services in Veins, Acupuncture, Plastic Surgery, and General Surgery.  That can be quite a lot.  But even with that said, it’s somewhat confusing as to what each of these items involves.  So I thought I’d make a list which doesn’t include everything, but covers most of what we do:

DR. TAMMY WU PROCEDURES:

DR. CALVIN LEE COSMETIC and BOTOX PROCEDURES:

  • Botox for cosmetic
  • Botox for headaches
  • Botox for hand and axillary sweating
  • Botox for TMJ (jaw pain)
  • Fillers (ie. Juvederm)
  • Lip Augmentation with Juvederm or other injectable fillers
  • Vein Laser
  • Vein Injections (ie. with Asclera)
  • Face Vein treatment
  • Acne Consultation
  • Skin Care Consultation
  • Cosmetic Mole Removal
  • Microdermabrasion
  • Chemical peels (ie. Obagi Blue Peel Radiance and Obagi Blue Peel)

DR. CALVIN LEE ACUPUNCTURE PROCEDURES:

  • Acupuncture trigger point deactivation for muscle pain
  • Acupuncture for back pain / neck pain
  • Acupuncture for buttock pain (ie. pyriformis syndrome)
  • Acupuncture for IT band pain (side of thighs wrapping to below knee)
  • Acupuncture for fertility
  • Acupuncture for TMJ (jaw pain)
  • Acupuncture for stress / anxiety
  • Acupuncture for allergies
  • Acupuncture for fibromyalgia
  • Acupuncture for depression
  • Acupuncture for hormones (hot flashes, acne, menstrual cycle)
  • Acupuncture for facial rejuvenation (cosmetic)
  • Acupuncture to boost the immune system
  • General wellness Acupuncture
  • Anti-nausea acupuncture for those undergoing chemotherapy or pregnancy

  SKIN CARE PRODUCTS:

  • Obagi Line
  • NIA 24 Line
  • Various Skinceuticals

 GRADUATED COMPRESSION SOCKS:

To recover faster from workouts, prevent varicose veins, and prevent injuries

  • Calf sleeves from Sigvaris and CEP brands
  • Full calf sleeves from Sigvaris and CEP brands
  • Dress socks from Sigvaris
  • Thigh high and Pantyhose compression from Sigvaris.

 Contact Us:

Surgical Artistry - Calvin Lee, MD / Tammy Wu, MD

 

Metronidazole Topical for Rosacea?

This is a note-taking blog for purposes of education – not for specific directed medical advice.

Metronidazole is a treatment available for Rosacea

  • Topical application of Metronidazole (meanning applied to the skin surface)
  • Metronidazole also comes as a pill form but this isn’t usually needed or indicated for Rosacea
  • Metronidazole is an antibiotic
  • Flagyl is the name a brand of metronidazole in pill form
  • As an antibiotic, Metronidazole is effective against anaerobic bacteria and protozoa.  It is a drug used for treating clostridium difficile infection (c. diff).
  • Topically, it comes as cream or gel
  • Metrogel is a brand (Metrogel 1%) as is Rozex.  And there are generics available for metronidazole gel or cream.
  • Many patients use metronidazole topical twice a day
  • Many patients of ours at Surgical Artistry, Modesto, report some dryness with the product and use it with a moisturizer.

Other uses of Metronidazole

  • Orally it has been used in Crohn’s disease
  • And orally, it has been used as part of the treatment for peptic ulcer disease

Obagi Rosaclear

  • a system designed by Obagi Medical for treatment of Rosacea
  • Metronidazole topical is part of the kit,
  • available as part of the rosaclear kit is a cleanser, toner, and a special tinted sunblock

What is Rosacea?

  • Some forms of it seems to be a skin infection which is related to blood vessel dilation and redness
  • Central facial redness, burning and stinging
  • visible red veins
  • bumps or blemishes
  • tight or itchy facial skin which may swell
  • Cause is unknown

What can our office in Modesto, do for Rosacea?

There are many treatments available for Roscea

  • We have Rosaclear available from Obagi
  • We have many Rosclear Sunscreen – tinted specially to hide and blend in the redness.
  • We have a vascular laser (Dornier 940, Germany) which is good for targeting the red vessels.
  • For some patients we can also prescribe clindamycin topical for rosacea

Sunscreen UVA vs UVB Protection Chart

Obagi Sunshield 50.  10.5% zinc oxideSummer time – that also means SunScreen time!  I consider sunscreens even more important than Botox for anti-aging.  And of course there’s no reason why Sunscreen and Botox can’t be used at the same time.

Sunscreen vs. Sunblock: Sunscreen is the modern term.

The term Sunblock seems to be going out.  It’s considered to be somewhat misleading because the term “block” implies total protection.  Sunscreen is used in place of sunblock these days.  A while ago, sunscreen was used to talk about chemical sunscreens and Sunblock was used to describe the ingredients titanium and zinc.

UVA vs UVB

Both are ultraviolet light spectrums – which are really part of a singular continuum.  But for the sake of categorization, UVA is longer wavelengths than UVB.  UVA has more penetration ability.  Both aren’t entire good for your skin in regards to aging and cancers.  So you want to shield from both.  SPF unfortunately only reflects UVB blocking ability.

Mineral vs. Chemical

I like the idea of mineral sunscreens where it doesn’t form a chemical compound with your skin and that it works more like a mirror.  But if you really dislike ultraviolet light damaging your skin, consider both.  My favorite is Zinc Oxide.

Here’s the Chart for Sunscreen active ingredient and it’s action against UVA and UVB.

zinc chart and other sunscreen ingredients against uv-a and uv-b

 

I found this wonderful chart on the internet.  I’m not sure of the source and I’ve seen it repeated in several different places.  I had to write this blog just so that I could have a copy of this picture somewhere so that I could refer to it when talking about Sunscreen.  As you can see from the chart, it is easy to have Zinc Oxide as your favorite because of its broad spectrum.

What about Vitamin D from the sun?

The Academy of Dermatology current position updated in 2011 recommendation on Vitamin D:

There is no scientifically validated, safe threshold level of UV exposure from the sun
or indoor tanning devices that allows for maximal vitamin D synthesis without
increasing skin cancer risk.

They basically recommend oral supplementation of vitamin D.

After Microdermabrasion and other skin procedures

After a Microdermabrasion or a chemical peel, we recommend that patients protect their skin with a zinc oxide sunscreens.  We also reinforce that with sunscreens, thicker is better – in other words – the strength of a sunscreen is dose dependent.

More Sunscreen Resources:

Thank you for reading my little review of my knowledge of Sunscreens.

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