Louisville Forehead Lift/ Brow Lift
Part 1- Goals

The optimal (youthful) appearing forehead and brow are difficult to quantify.  In fact, the ideals have changed over time.  Years ago, the ideal was based solely on brow position, as there was no good treatment of forehead wrinkles.  In that time, the goal was a high, mid brow arch.  Unfortunately, this resulted in the chronically "surprised" look.  With the advent of neuromodulators (botulinum toxins), the environment has drastically changed.  A youthful forehead is gently sloping, without deep vertical or horizontal wrinkles.  Brows differ in men and women.  Optimal brows in men are typically more horizontal, without a significant arch.  The brow is centered on the supraorbital rim (bony ridge above the eye).  Optimal brows in women lie above the supraorbital rim.  Although there are many variations, the optimal brow is approximately 2.5cm above the mid-pupil (center of the eye).  The brow continues to arch superiorly, and peaks at a level in line with the lateral limbus (the outside of the pupil).  There are now many different tools available to address problems of the forehead and eyebrow.  All of these can now be used to generate a natural, youthful look.  All-the-while, avoiding the permanent "surprised look".  The surprised look is great when watching a horror film,  not so much when looking at your credit card statement.  More to come.....


Guyuron, Bahman, and MichelleLee. "A reappraisal of surgical techniques and efficacy in forehead rejuvenation." Plastic and reconstructive surgery 134.3 (2014):426-35.

www.LittlePlasticSurgery.com

Scar Prevention
Part 6- To Sum It Up

As we have seen, there are many options for scar treatment and prevention.  Many of which are untested or unproven.  The choices are:  spend hundreds to thousands of dollars on unproven therapies, or, reasonable, cost-effective treatments which can provide excellent results. When recommending therapies to my patients, I have to go with what is safe and effective, based on sound scientific data.  In the end, it always comes down to what I would recommend for my own family-
1) Sun protection- All scars need adequate sun protection (sunscreen of SPF 30, with correct application) for atleast one year after surgery
2) Plain-paper taping of incisions for atleast 6 weeks
3) Scar massage
4) Finding a good surgeon to perform your procedure
5) Save your money for a vacation, away from cellphones, the internet, and the Real Housewives of Beverly Hills.
More to come...

www.LittlePlasticSurgery.com

Scar Prevention
Part 5- Snake Oils and The Placebo Effect

Scar treatment and prevention has been subject to countless untested and unproven therapies.  Patients often swear by treatments that are known to have little to no effect.  Indeed, good studies have demonstrated both subjective and objective improvement in various diseases, when treated with placebos ("sugar-pills).  Recent studies have documented improvement in lung function in those with asthma, when treated with placebos.  Other studies have shown that placebos may be 80% as effective at treating depression as standard medical therapy.  The reasons behind this are complex and poorly understood.  Expectancy plays a role- subjective improvement because you expect improvement.  The expectancy effect is real.  It causes changes in brain chemistry, and can stimulate the production of neurotransmitters, similar to that caused by medications.
So, what does this have to do with scars?  There are countless untested and unproven scar therapies being marketed.  Whether scar improvement is due to the "therapy" or to the placebo effect, is anyones guess.  Often, just getting a patient more involved in their treatment, leads to better results.  Unfortunately, the placebo effect can be taken advantage of.  Scar treatments can easily cost thousands of dollars.  These treatments may sound exciting and complicated- scar creams that contain estrogens, steroids, growth factors, and vasodilators.  Unfortunately, there is little to no data that these are any better than lotion from Victoria's Secret.  So, in the end, if I just want to do something,  it is a good excuse to go to Victoria's Secret.  More to come...

Dutile, Stefanie, Ted JKaptchuk, and Michael EWechsler. "The placebo effect in asthma." Current allergy and asthma reports 14.8 (2014):456-456.

www.LittlePlasticSurgery.com

Scar Prevention
Part 4- Sun Protection

A hyperpigmented or red scar is much more noticable than a hypertrophic (raised) or widened scar.

Many things can lead to a reddened scar, including infection, wound tension, inflammation, and UV-exposure.  Of these things, UV-exposure is one of the only places that a patient can intervene.  If a fresh scar is exposed to significant sunlight, it tends to turn red.  To make things worse, it tends not to fade back to the color of the surrounding skin.  After I explain this to patients, the next question is whether they need to use SPF 75 or 100.  The marketing of sunscreens is in flux at this point.  In fact, there is a push to limit the advertised SPF to 50.  At these high levels, there is very little difference.  In fact, there is little difference in the incidence of sunburn between SPF 15 and SPF 30, if applied correctly.  "Applied correctly" is the key term.  Most people do not apply sunscreen in sufficient amounts or re-apply often enough.  If applied incorrectly, like I do, the incidence of sunburn is decreased when SPF 30 is used, compared to SPF 15.  In the end, I recommend sun-protection (SPF 30 sunscreen) to patients any time they are in the sun for atleast the first year after surgery.  Good sunscreen can be expensive, and costs a fortune when you need it the most- on a cruise or at the ski resort.  I still flinch at the time I had to grab a small bottle at the Hilton Head marina.  Nevertheless, it is always cheaper than a scar revision procedure or any of the unproven scar creams on the market.  More to come...


Due, Eva, et al. "Effect of UV irradiation on cutaneous cicatrices: a randomized, controlled trial with clinical, skin reflectance, histological, immunohistochemical and biochemical evaluations." Acta dermato-venereologica 87.1 (2007):27-32.
Pissavini, Marc, and BrianDiffey. "The likelihood of sunburn in sunscreen users is disproportionate to the SPF." Photodermatology, photoimmunology & photomedicine 29.3 (2013):111-115.

www.LittlePlasticSurgery.com

Scar Prevention
Part 3- Taping
Semi-occlusive dressings have been shown in multiple studies to be associated with improved scar appearance.  This can be acheived in a variety of ways, most notably, the practice of taping over incisions.  The reason taping improves scar appearance is not well understood, but thought to keep scars hydrated and decrease tension across wounds.  More recent data shows that there are small nerve fibers in scars that can sense pressure and tension.  When tension is sensed by these fibers, neurotransmitters are released that ultimately lead to changes in the architecture of scars and worsens their appearance.  Taping acts to shield a scar from activation of these fibers, decreases wound tension, and keeps the scar hydrated.  Regardless of the mechanism, prolonged taping of an incision has been shown to improve the scar quality.  Other recent data shows atleast equivalence to silicone-based gels/ sheeting.  Silicone-based preparations can be very expensive, wheras, a roll of paper tape sells for about $3.00 at Amazon. This data is not widely publicized, as the market for "scar creams" is a multi-million dollar affair.  No company gets rich on $3.00 rolls of paper tape.  In the end, I generally recommend the simple act of taping incisions for 6 weeks after surgical procedures.  More to come...

Yagmur, Caglayan, et al. "Mechanical receptor-related mechanisms in scar management: a review and hypothesis." Plastic and reconstructive surgery 126.2 (2010):426-434.

Tollefson, Travis T, et al. "Comparison of effectiveness of silicone gel sheeting with microporous paper tape in the prevention of hypertrophic scarring in a rabbit model." Archives of facial plastic surgery 14.1 (2012):45-51.

www.LittlePlasticSurgery.com

Scar Prevention
Part 2- Vitamin E

Immediately after I explain the role and alternatives to silicone-based scar preparations, many patients ask about the use of topical Vitamin E.  Afterall, most grandmothers swear by it (atleast mine does).  Vitamin E is a tocopherol with antioxidant properties.  It is theroized to act by inhibiting collagen formation, inflammation, and fibroblast proliferation (all of which are needed in normal wound healing).  Only a few studies have demonstrated any benefit, and only in conjunction with other therapies.  Most studies have shown no improvement and a high prevalence of contact dermatitis (rash).  Nevertheless, the placebo effect is real- some patients feel improvement, just by doing something.  So in the end, I generally do not recommend the use of Vitamin E for scar treatment or prevention.  However, I am not one to argue with grandmothers.  More to come...

http://www.ncbi.nlm.nih.gov/pubmed/21856542
www.LittlePlasticSurgery.com

Scar Prevention
Part 1- Silicone Scar Creams

Wound healing and scar formation is a very complex process.  Poor scar healing can result from a variety of factors.  Due to the different factors, there is no single therapy that leads to elimination of scarring. Nevertheless, most patients are looking for the "magic cream".  The most widely marketed scar preparations are silicone-gel based.  Silicone sheets and silicone gels are widely considered to be the only non-invasive therapy for scars.  Many studies have shown improvement in scar quality and decreased risk of poor scarring (hypertrophic-scarring, keloids).  Although the exact mechanism is unknown, it is thought that the silicone acts as a sealant and keeps the scar hydrated.  Hydrated wounds are generally known to result in imrproved scarring. So in the end, silicone preparations have a role in scar management.  However, there are many other factors that influence wound healing.  As we will soon see, other therapies may just effective as these silicone products.  More to come......

http://www.jprasurg.com/article/S1748-6815(14)00173-9/abstract

Finally, a thoughtful and amusing look at untested and unproven skin care products
Nerium- Barefacedtruth.com