A Blog by Kenneth Rothaus, MD

     There is an interesting article in the March issue of the Aesthetic Surgery Journal (www.aestheticsurgeryjournal.com) from Drs. Wong, Gabriel, Maxwell, and Gupta of Loma Linda University in California. This review article which was titled: Bleeding Risks of Herbal, Homeopathic, and Dietary Supplements: A Hidden Nightmare for Plastic Surgeons? (Aesthetic Surgery Journal 32:332-348)

     Soon after I moved into my current office, I took care of the mother of one of the nurses that I work with at the New York Presbyterian Hospital. This woman desired a facelift and during her consultation her daughter and I both reviewed all her medications. We made sure that she stopped all the common medications that are known to cause bleeding during surgery. Just before we were scheduled to do her facelift, she developed a pigmented lesion on her leg about which we were all concerned and a decision was made to biopsy this lesion before the facelift.

     During the removal of this lesion (which fortunately turned out to be benign), we encountered an inordinate amount of bleeding. The patient insisted she had stopped all the medications which are known to interfere with normal blood clotting and I insisted on a hematology consult.  The blood tests ordered by the hematologist turned out to be abnormal. We went over all her medications again and could not find anything to account for this abnormality. The patient finally added as an aside that she also took garlic supplements. 

     Garlic supplements are known to cause bleeding and once stopped in this patient, her blood tests all reverted to normal. The next month we performed her facelift without, fortunately, any bleeding problems. The patient was very happy with her result and I was very happy that we had stopped her garlic supplements. 

     The authors of the above mentioned article divided these alternatives and "natural" remedies into 3 categories: Herbal supplements and herbal extracts, herbal teas, and homeopathic medicines and other dietary supplements. Some of the more popular of the herbal medications covered in this article included bromelain, garlic, Ginger, ginkgo, ginseng, licorice, read chili pepper, and saw palmetto. The herbal teas were seasonal tonic and te gastronol. The homeopathic medicines included: chondroitin, glucosamine, fish oil, Arnica Montana, and vitamin E. All of these agents as well as those not listed here are known to increase the risk of bleeding and hematoma both pre-and postoperatively. 

     The authors stress the importance of careful screening of patient's for all these medications and recommend stopping them as long as 3 weeks prior to any surgical procedure and not resuming them for the equal than time afterwards.  Thus, it is extremely important that you inform your doctor of everything you are taking including all prescription medications, vitamins, herbal medications, herbal teas, and homeopathic medicines. Failure to do so, may result in many complications both during the surgery and afterwards.  

 

     Plastic surgery comes with many perks.  There are obvious physical rewards, emotional benefits and the satisfaction of achieving personal goals.  As anyone knows, achievements don't come without some responsibilities.  And when it comes to your plastic surgery procedure, one major responsibility is smoking cessation.   Although this proposes a challenge for any habitual smoker, your surgeon’s got your best interest at heart.  Aside from the obvious health risks, there are several reasons why your doctor urges you to banish the butts.  

 

Smoking before and immediately after your procedure will commonly affect your result.  It can lead to complications like vascular compromise, skin loss, infections, delayed healing, poor scarring and other issues - all of which would have a deleterious influence the outcome of your surgery.  Furthermore, when you’re electing to have plastic surgery, it’s most likely to accomplish an improved aesthetic or visual appearance.  With that in mind, smoking is especially counterintuitive as smoking accelerates the signs of aging.  Unbelievably, it can still require a great deal of effort for surgeons to convince patients that they’re not just blowing smoke.

Today we have more choices than ever before when deciding on ways to improve our appearance. There are a myriad of technologies, procedures, and products available, which for many patients, is the primary focus. However, we believe that there are ten key points that should be just as important, or more so, than which procedure to choose.

1. PLASTIC SURGEON

If you’re thinking about a surgical enhancement, you want to do your homework to choose the right person to hold the scalpel. In New York City alone there are literally dozens and dozens of plastic surgeons, so you have lots of choices. Plastic surgeons have many years of rigorous surgical training, as opposed to a weekend course or side interest. 

2. BOARD CERTIFICATION

You want to be certain that your surgeon is “board certified”. To acquire board certification, surgeons must go through further testing and analysis of surgical results. Plastic Surgery is one of the 24 medical specialties recognized by the American Board of Specialties (ABMS). If a doctor is a member of the American Society of Plastic Surgeons (ASPS) or the American Society of Aesthetic Plastic Surgeons (ASAPS), you can be ensured that they are a board certified plastic surgeon. 

3. EXPERTISE

When you consult with physicians, it's important to know about their qualifications, such as how many years they’ve been practicing and how many times they've performed the procedure that you’re inquiring about. Dr. Rothaus has over 25 years of plastic surgery experience and performs cosmetic surgery of the face and body daily. You can request to view a collection of before and after photos or speak with staff members who have had plastic surgery themselves.

4. TRAINING & METHODS

Based on your cosmetic ambitions, there could be an array of surgical options. Liposuction tummy tucks, facelifts, and breast augmentations are examples of such cases. At your surgical consultation, talk to your doctor very specifically regarding your goals and concerns. He or she can use this detailed information to advise you on the procedure and technique most appropriate for your unique needs. Dr. Rothaus's thorough training in plastic surgery has earned the utmost respect for his surgical quality and proficiency. You can be assured that he will discuss every approach to your procedure when you meet.

5. AN ATTENTIVE DOCTOR AND TEAM

A good doctor-patient relationship with your surgeon is something all patients want. Therefore, when you select a surgeon, you're also selecting his or her office. The staff, the facility, their character and reputation, their history and length of time in the community, and their responsibility to quality patient care and safety are important key points. A group of loyal professionals is something you want to check for signs of. Dr. Rothaus and his outstanding team are known for providing a personal approach and unsurpassed expertise to achieve the ultimate in patient care and have been a part of the community for over 25 years.

6. CARE – BEFORE AND AFTER SURGERY

Make certain that you know how the practice will communicate with you both before and after your surgery, as well as how they will care for you. Are the staff members involved with your care appropriately licensed and certified? Our staff considers patient education a high priority and ensures that you are fully disclosed of any and all details regarding your procedure – from what to expect and how to prepare to the specifics of your recovery process. A careful review of your health history will also be completed. We stay in close communication with you prior to your surgery and after it has been performed. 

7. HOSPITAL PRIVILEGES

“Hospital privileges” means that a physician has an alliance at a local accredited hospital. Ensure that the surgeon you are considering for a procedure has “hospital privileges” in that particular procedure at a local accredited hospital. Dr. Rothaus is a positively regarded member at New York Presbyterian Hospital and carries privileges to perform the procedures done in our office-based operating rooms at the hospital.

8. OPERATING & RECOVERY ROOM STAFF

The certification, licensure and expertise of the surgical and recovery team is very important. When you have surgery under general anesthesia at our practice, you can be certain the following people will be in your operating room (OR) with you: your plastic surgeon, a physician anesthesiologist, a Registered Nurse (RN) who “circulates” and/or “scrub tech” that assists the surgeon. While you are recovering after your procedure in our recovery room, another RN will be caring for you. Our registered nurses and physician who work in our OR are certified in Advanced Cardiac Life Support (ACLS certified). This is a high standard of care and we believe it is a standard that you should look for.

9. ANESTHESIA

Another crucial standard that we believe in is that anesthesia is administered by a board certified anesthesiologist, which indicates that the doctor delivering your anesthesia is qualified in the ABMS recognized specialty of Anesthesiology. Occasionally in other practices, general anesthesia is given by a Certified Registered Nurse Anesthetist (CRNA) or even the surgeon or an RN. Because that most cosmetic surgical procedures are performed under deep sedation, at our practice, you can be certain that any case done under any type of anesthesia is administered by a qualified and accomplished board certified anesthesiologist.

10. FACILITY

We encourage you to have your surgery in an office-based surgical facility that has one of the three following accreditations: AAAASF, JACHO, or AAAHC or in a hospital-based operating facility. Accreditation by one of these groups validates that their standards of care are determined and investigated by a third party. Our operating rooms are AAAHC accredited, which tells you that we maintain the highest standards. Our facility is inspected a regularly and we satisfy crucial criteria for safety, equipment, facility, staff, and surgeons.

 

Our desire is for you to have an extraordinary and safe cosmetic surgical experience and we hope this information has been helpful in your search! 

 

     Unquestionably, over the recent years, lasers have transformed treatments for many skin imperfections such as sun damage, scarring, skin texture, wrinkles and skin tightening. With factional technology, which was introduced over seven years ago, tiny points of laser light can be distributed by a laser handpiece or scanner in a pattern that leaves columns of treated tissue surrounded by normal, uninvolved skin. These advances in laser technology provide precise control of the depth of penetration, the energy used, and the surface area covered in the treatment. This allows the skin to be treated not only intensely enough to achieve one’s goals, but also leaving a larger margin of safely and hence a quicker healing time.

     It’s clear that this is an exciting and promising technology when it comes to treating brown hyperpigmentation, fine lines, scarring, wrinkles, and abnormalities in skin texture and laxity. We are pleased to announce the new addition of the DEKA SmartXide50 fractional CO2 laser to our practice. 

     This particular higher power device is especially flexible with regards to the parameters of the treatment, thus, increasing the safety profile. Because the patient’s epidermis is not totally ablated (removed) as was the case in the past, there is a more accelerated healing time. This varies from approximately 3-7 days depending on how aggressive a treatment is performed. Even in higher energy treatments, patients are left with some redness following the initial healing phase that subsides fairly quickly and can usually be covered with makeup. The columns of tissue which are treated or ablated by the laser lead to stimulation of the patient’s own collagen. This results in continuous improvement that occurs over a period of months and leads to a longer lasting effect of skin rejuvenation. 

     One of the significant benefits of this type of procedure is that it can be performed with topical and local anesthesia. Patients typically report very little discomfort during their treatment. The most commonly treated areas are the face, eyelids, neck, chest and hands - not surprisingly, as these are some of the first areas to show the signs of aging skin. 

     If you’ve been considering freshening up your skin’s appearance, we’d be happy to answer any of your questions and explain the advantages of this revolutionary procedure. We’re confident that you’ll agree - this truly is an investment in you! 

Dr.Rothaus has been very busy lately with numerous speaking engagements both locally and internationally.  

In May,  Dr.Rothaus was invited to speak at in Israel at the Haddasah Hospital/University in Jerusalem and Tel Hashomer Hospital in Tel Aviv. At these prestigious institutions, Dr.Rothuas spoke to local plastic surgeons about SlimLipo laser liposuction, giving his impressions of the procedure and discussing his own research findings related to its safety and efficacy. His talk was extremely well-received and generated much discusion.

More locally, Dr.Rothaus spoke at the St.Regis Hotel in New York City this past weekend.  Again, he was a guest lecturer on SlimLipo.  Dr.Rothaus is now widely considered to be one of the more experienced SlimLipo surgeons in the world.  He has sent the past several years developing and refining the techniques that he has been traveling around the world teaching to other plastic surgeons.  

Dr.Rothaus is very pleased to announce that effective immediately he will be the FIRST and for the present ONLY New York City plastic surgery practice offering Exilis technology. Exilis uses radiofrequency energy for targeted, effective and rapid body contouring and facial rejuvenation. This high-frequency energy causes heating of the deep tissues.  This is felt to result in the decrease in fat cell volume, allowing for sculpting and reshaping, while simultaneously increasing collagen production resulting in tightened, smoother skin. The treatment is painless, non-invasive and very quick.  Best results are visible after 4 weekly 15 minute sessions. More information about Exilis may be found at their website, www.exilis.com .  Dr.Rothaus is very impressed with the technology and is very excited to offer this to his patients.

When I began my surgery and plastic surgery residencies, I was baffled by the commonly issued recommendation that sutured wounds MUST be kept dry to prevent infection.  Patients were counseled to cover the area when showering or to avoid washing the area completely during the period immediately after surgery.  This always seemed counterintuitive to me from a hygiene perspective. Shouldn't we encourage our patients to keep wounds clean by gently washing with soap and water?  The wounds are generally sealed after 12hours and the suture materials now use are monofilament synthetics which behave quite differently from the silk sutures used in the past.   I decided to go with my clinical judgement and always instructed my surgical patients to wash the wound sites.  For example, if you have had a facelift in my practice, you will know that your written instructions indicated that you should shampoo your hair daily after surgery.  By following this common sense approach, I have a post-op infection rate of virtually zero in my practice.  Recently, an 800 patient Australian study verified my thoughts exactly. Thus, it remains my clinical judgement which is being confirmed by larger studies, that patients can shower and wash their wounds with no additional fear of infection and may, in fact, decrease their infection rate and other wound related morbidity.  Any patient must, of course, discuss their particular diagnosis, wound, medical problem and care with their individual physician and surgeon and should not rely on this or any other blog for definitive medical advice, care or treatment.

Summer is finally here and as the sundresses, shorts and sandals emerge from the back of the closet, its important to remember to ward off sun damage to your skin by using a high-quality sunblock or suncreen that protects against ultraviolet (UV) rays. Sunlight contains three types of UV rays - UVA, UVB and UVC. Fortunately, the ozone layer blocks out the most dangerous UVC rays and some of the UVB rats.  Long-wave UVA rays pass through the ozone layer unfiltered, deeply penetrate the skin and are known to cause photoaging and wrinkling.  Short-wave UVB rays cause sunburn and are implicated in basal cell and squamous cell carcinomas.

UV radiation can be blocked by chemical or mechanical sublocks. Chemical sunblocks are typically synthetic compounds which work by absorbing the UV light.  They are absorbed into the skin and often into the systemic circulation.  They can be degraded by the UV light and and can take up to 20 minutes after application to the skin to reach effectiveness.  Therefore, it is important to apply a chemical suncreen before sun exposure and then again at regular intervals during.  Some chemical sunblock ingredients include dixoybenzone, oxybenzone, PABA and PABA esters and cinnamates. 

Mechanical sunblocks reflect and scatter UVA/UVB light.  These sunscreens typically contain titaniun dioxide and zinc oxide as active ingredients.  I prefer mechanical sunblocks as they begin to work immediately after application and systemic absorption tends not to be a problem.  In the past, these preparations were thicker, opaque, and somewhat  cosmetically unacceptable (think the white blob of sunblock on a lifeguard's nose). With currently available technology such as micronization, the titanium and iron particles have been processed to be much smaller resulting in translucent suspensions that are thinner and smoother than in the past. 

As far as the Sun Protection Factor (SPF), you should aim to use a suncreen with at least an SPF of 30. Chemical sunblocks typically do not provide additional protection beyond SPF 30.  Mechanical sunblocks are usually by their very composition at least SPF 45-50, so you by choosing a mechanical sunblock, you are automatically at what I consider to be the a maximally efficacious level.  In either case, frequent reapplication is of the chosen sunblock is key to skin protection. Additionally, don't forget to employ some other common sense tactics such as wearing a wide brimmed,sunglasses and protective clothing, as well as avoiding the sun during the hours of 10am and 2pm to maximize your skin's protection.