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GROWTHS ON SKIN
There are several skin lesions that are very common and almost always benign (non-cancerous). These conditions include
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 Abdominoplasty (Tummy Tuck) |
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Abdominoplasty is extremely useful in removing unwanted fat, if there is considerable laxity of the abdominal muscles and excessive skin, particularly following childbirth or very large weight loss from other reasons.
During weight gains (example childbirth), the abdominal muscles are often stretched to such a point that they never regain their pre-birth tightness. This condition is referred to as diastasis recti. With weak abdominal muscles, the intestines tend to push forward. This can put a considerable strain on the spine causing a fair amount of back pain. It may even cause some difficulty with bowel movements. The skin, during pregnancy, actually grows. If the weight gain is excessive, the skin might not go back to its pre pregnancy stage, and liposuction alone can not account for adequate shrinkage. The excess skin and fat needs to be surgically removed.
In order to achieve a flatter, tighter abdomen without the excess skin an abdominoplasty (tummy tuck) is performed. It is generally an out-patient procedure, but under certain circumstances can be done in the hospital with an overnight stay. The procedure is generally performed under general anesthesia, but in select cases it can be performed under intravenous sedation and local anesthesia. The 2 - 4 hour procedure involves elevating (separating) the skin and fat from the underlying abdominal muscles. The belly button (umbilicus) is cut out from the skin and left connected to the deep tissues from which it originated. The muscles are then tightened, making the waist narrower and restoring their pre-stretched out position. The excess skin and fat are excised and the new flap is sutured to the bikini line incision site. A hole is made where the belly button lies under the flap, and then it is reconnected to its new site.
Drains are often used and removed within 3 - 7 days. The sutures are usually removed after one week. Walking is allowed and encouraged immediately. In fact, walking is the most important thing in preventing the worse complication of abdominoplasty - pulmonary embolism from a clotted (thrombotic) leg vein.
Complications and risks
Infection is a possible complication, yet fortunately quite rare. The biggest risk of infection is probably from bacterial contamination up through the drain site. This can be minimized by keeping the drain sites clean and covered with antibiotic ointment. Poor healing of the scar is another risk. The scar usually starts healing promptly with typical redness which ultimately fades over time (one year). In rare circumstances, if there is compromise to the blood flow within the skin (flap), the tissue around the scar can breakdown, resulting in a dehiscent wound (the tissues die and the wound separates). Such a problem requires conservative care and patience until it heals. There can also be some contour irregularities that might require further treatment or perhaps a little liposuction. |
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| The Space Lift - Autologous Fat Transplantation (fat - grafting) |
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The concept of removing fat from one part of the body and injecting it into another part of the body is one of the most exciting to be added to the field of cosmetic and reconstructive surgery. While fat transplantation has been done in various ways for some time (first recorded in the late 1800's), the concept of fat transplantation by micro-injection is relatively new.
Why would we want to use fat as a grafting tool?
For one thing, we should realize that one of the main causes of aging is the apparent loss of fat in one's face. The skin may be thought of as an envelope and the underlying fat and muscles as the contents. As the contents thin out, then there will be a relatively larger envelope. In the case of the face, this will appear in the form of sagging or wrinkles. If we could replace fat in some of these areas, then we might be able to restore a more youthful and attractive appearance.
There are also cases where fat would be useful to help repair certain deformities. Many cases exist where people have sustained fat loss as a result of trauma, or from an occasional reaction to an improperly injected medication, or even as a result of a birth defect. Fat could also be used to enhance certain facial features such as areas around the cheeks or chin. Indeed, fat can also be used to sculpture other parts of the body, such as the buttocks, combining it with liposuction surgery.
How does fat-grafting work?
Basically, by using liposuction techniques, fat can be harvested from one part of the body and then re-injected into another part of the body where it is needed. Since the fat is injected in the form of free cells then it must be re-vascularized in order to survive. Therefore, the fat that is not re-vascularized (i.e. does not obtain a blood supply) will subsequently die and be reabsorbed into the body. This is different from collagen which is ultimately reabsorbed because of a rejection reaction in which the body eventually clears the material because it is a foreign substance. Fat does not survive equally well in different parts of the face or body. For example, it survives very well when we use it to fill out the hollows around the eyes we often see congenitally or with aging, but does not do as well around the mouth. In such a case, only part of the transplant would survive thus necessitating further treatments until sufficient quantities have survived to obtain the desired result. Recent animal studies suggest that fat graft survival is enhanced by implantation into muscle. Muscle, of course, has superior vascularity and should improve the chances of the re-vascularization of the fat cells. Treatments can generally be repeated every two or three months because the fat that does not survive is reabsorbed rather quickly. Thus, after a few weeks all of the swelling will be gone and the surviving fat will remain. It should last indefinitely because it is now a living part the patient.
The operation itself usually takes from 1 ˝ to 2 hours, or it can be done in combination with other procedures such as a face-lift or blepharoplasty. It is usually done under local anesthesia with intravenous sedation. It can be done in the office surgical suite as an out-patient without any need for hospitalization. The fat is usually taken from the lower abdomen through a tiny incision hidden in the belly button or pubic area, or from the inside part of the thighs through a tiny incision hidden in the crease of the groin. It can however, be taken from other areas of the body as well. After the fat is harvested it is "washed" and then readied for injection. The areas to be treated then receive the fat by injection through inconspicuous sites. The patients are started on antibiotics prior to surgery and for a few days thereafter to prevent infection (which is very rare). Pain is minimal yet a light narcotic like Tylenol with codeine is sufficient if there is the need for analgesia.
Uses of Fat Grafting
Fat grafting can be used for several specific areas. In the face there are two areas that seem to show the effects of fat loss the earliest, namely the area around the mouth and then the area around the eyes. Most likely this occurs because they are areas sitting right on top of muscle which is frequently in use. Realize that we all start out with a layer of fat between the skin and muscle, but over time there is a gradual dissipation of the fat which then allows the skin to come in closer approximation with the muscle below. The contractions of the muscle directly on the skin are a major cause of the breakdown in the skin which shows up as small lines and creases. Around the lips this is most noticeable and thus an excellent area for fat-grafting, although one that usually needs repeated treatments. The area around the lower eyelids is a good area to treat. As the cheek thins out in this area the underlying orbital structures become more visible. Often the bony orbital rim becomes rather prominent. Many times we see this problem after traditional lower lid blepharoplasty because too much fat has been removed. This is seen with the upper eyelid also. With traditional blepharoplasty, the upper eyelid, though no longer sagging, often ends up looking sunken and abnormally rounded. We can place fat back around the brow to re-create the softer images of the youthful eyelid. The creases between the nose and lips (nasal/labial folds) often become more prominent as fat is lost from the cheek area. It too can be treated. Other areas treated in the face include the cheeks and occasionally the chin. Deep scars, congenital deformities and other post-surgical defects can also be treated.
Fat grafting can also be used elsewhere on the body. The "aging hand" appears that way also because of loss of fat under the skin and it too, lends itself well to fat-grafting. Fat grafting can also be done to build up areas such as the buttocks. If there is excessive fat around the hips or thighs, this can be suctioned, cleaned and implanted into the buttocks to sculpt out a rounder silhouette. Again, it appears results are enhanced by injection deep into the muscular tissue.
One other special area needs to be mentioned, namely the breast. While it seems an ideal area for augmentation through fat-grafting it is also a fairly controversial area at this time. While it is true that fat-grafting does work in this area there are some real and theoretical problems with it here. The most regarded problem is that of micro-calcification. As noted before, not all of the fat survives upon transplantation. When the fat cells die they are mostly reabsorbed, but during the process there is often some scar tissue formation which could go on and become slightly calcified. The fear is that when a woman gets a mammogram there may be micro-calcifications which would thus warrant biopsies to rule out a possible cancer.
Like any operation there are some degree of risks. Most people are worried about unfavorable results, particularly lumpiness. Initially, there may be some firmness in conjunction with local tissue swelling, but as that settles down it is very rare to have firm lumps, as fat itself is very soft. While some doctors over-correct the treated areas I have found this to be unnecessary. In areas, such as around the eyes, the fat tends to "take" very well and over correction may lead to excessive bags. On the other hand, areas such as the lips do not take the graft as well and overcorrecting there will only lead to wasted fat which can not be re-vascularized and will thus reabsorb. I do however, tend to put more fat around a larger area of the lips, in a sense over correcting by area. Infection, bleeding, or problems related to anesthesia are all exceedingly rare. Lumpiness is avoided by keeping the placement deep.
Fat-grafting through micro-injection may just well be the most revolutionary procedure to come along for the treatment of the aging face in the last decade. It is not a perfect procedure, but it is safe and replaces the needed material with the bodies own source. |
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| Blepharoplasty (Eyelid Tucks) |
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The eyes and the mouth are the first things we see when we look at each other. With aging, there is a general loss of volume, principally fat, from under the skin, and damage to the skin. This results in the appearance of saggy eyelid skin, bags under the eyelids, and circles or lines around our eyes. Depending upon the skeletal position of the eye, genetics, and various habits, we can expect to find a broad range in the way we age around the eyes.
In the traditional sense, improving the appearance of the eyelids has involved the removal of excess skin and fat from around the eye. Such standard approaches to eyelid surgery may leave the patient looking better, but not necessarily as if they have more youthful looking eyes. |
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By looking at the real cause for the aging eyelid, the operation can be manipulated to include replacing, not just removing, fat from around the brow and the cheek. Combined with some of the more standard surgical approaches.
There are several ways to accomplish the goal of improving the eyelids and ultimately the appearance of the eyes. First, in mild conditions of early aging, fat grafting alone may be useful. In some cases, a chemical peel or a laser resurfacing of the eyelids, along with fat-grafting, may do the trick. And of course, in more advanced cases, it is often most expedient to surgically remove excess skin, maybe tightening the saggy lid, and alter fatty bags, as well as fat-graft, in order to achieve optimal results. Indeed, there are times when fat-grafting is not indicated, such as in young people who have congenitally baggy eyelids caused from excess fat. In such cases, the fat can be removed without an incision in the skin.
The operation is performed on an out-patient basis, usually with intravenous sedation and local anesthesia. When the upper eyelid is operated upon, an incision is typically made in the eyelid crease (in the area corresponding to the insertion of the levator muscles). When operating on the lower lid, the incision is either made just under the eyelashes or as noted above, inside the eyelid in the conjunctiva. Fortunately, eyelid scars tend to heal very well and are rarely conspicuous when fully healed. An antibiotic ointment is usually kept continually over the suture line as this helps speed the recovery and optimize the quality of the wound.
Complications and Risks
The risks of operating on the eyelids include poor results. There may be bleeding under the skin causing a hematoma. Infection is extremely rare. Blurred vision is generally temporary, though in very rare cases blindness has been reported. The eyes may tear excessively and dry eyes, also, have been reported, though, again, usually temporary.
The procedure is not painful and the recovery is usually quite quick, with suture removal around five days after surgery. Patients can often return to work within a few days. The healing process varies from person to person and according to the nature of the operation. Generally, there is initial swelling and bruising which quickly settles within a week, though it might take longer if one has had previous eyelid surgery.
Often times the area of the suture line will get thicker several days or weeks after surgery. Often patients worry about redness in the scar. With proper care and avoidance of sun exposure this usually fades away within a few weeks. Stubborn cases may take longer to fade, but this is rarely a problem.
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Freckles
Freckles are flat, circular spots that typically range in the size of the head of a nail. The spots develop randomly on the skin, especially after repeated exposure to sunlight and particularly in persons of fair complexion. Freckles vary in color -- they may be red, yellow, tan, light-brown, brown, or black -- but they are always darker than the skin around them since they are due to deposits of the dark pigment called melanin.
The word "freckle" comes from the Middle English "freken," which, in turn, came from the Old Norse "freknur," meaning "freckled."
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FRECKLES BEFORE AND AFTER LASER TREATMENT |
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What types of freckles are there?
There are two basic types of freckles -- both with somewhat strange names -- ephelides and lentigines:
- Ephelides (singular: ephelis, the Greek word for freckle): This term refers to flat spots that are red or light-brown and typically appear during the sunny months and fade in the winter. They are most often found in people with light complexions and in some families, they are an hereditary (genetic) trait. .
- Lentigines (singular: lentigo, from the Latin word for lentil): Children may develop a small tan, brown, or black spot which tends to be darker than an ephelis-type freckle and which does not fade in the winter.
What are "age spots"?
The lentigines that develop in older adults are often called "liver spots" or "age spots." Both terms are misnomers. While freckles do tend to appear over time, they are not in themselves a sign of old age. Instead, they appear on sun-exposed areas in people who have a genetic tendency to develop them. So, they are by no means purely a function of age.
How do freckles develop?
The sun and sun-tanning lights emit ultraviolet (UV) rays.
After exposure to sunlight, the outer layer of the skin (the epidermis) thickens and the pigment-producing cells (the melanocytes) in the skin produce the pigment melanin at an increased rate.
People differ a great deal in their reaction to sunlight.
People with dark complexions are relatively less sensitive to sun exposure than fair-skinned persons. However, persons with dark skin are not entirely resistant to the effects of the sun, and they, too, can become sunburned with prolonged exposure. Persons with blonde or red hair are especially susceptible since they tend to be the fairest skinned.
Irrespective of skin color, it is the uneven distribution of the melanin pigment in the skin that results in freckling. A freckle is nothing more than an unusually heavy deposit of melanin at one spot in the skin.
How important is heredity with freckles?
The answer, it now appears, is: "Very important." In studies of twins, including pairs of identical twins and pairs of fraternal (nonidentical) twins, it has been found that among identical twin pairs, there was a striking similarity in the total number of freckles found on each person. Such similarities were considerably less common in fraternal twins. This clearly confirms that the occurrence of freckles is influenced by genetic factors. In fact, the variations in freckle counts appear to be due largely to heredity.
What is the medical meaning of freckles ?
True freckles pose no health risk at all. This is true for both ephelis-type and lentigo-type freckles. They are all absolutely harmless.
Concern about freckles arises when they are confused with the following, more serious conditions:
• Lentigo maligna ("malignant freckle") -- This is a rare condition that generally occurs on the faces of older adults who have a history of considerable sun exposure. Over the course of many years, this condition may, if untreated, develop into a malignant skin cancer . There are of course many hundreds of ordinary facial freckles for every one that is potentially malignant.
• Melanoma -- This very dangerous form of skin cancer may appear even in young people and on parts of the body that are exposed as well as those that are not exposed to the sun. About 40 to 50% of melanomas develop from pigmented moles. However, compared with freckles, melanomas tends to be larger, darker, and more irregular in color and shape than an ordinary freckle.
• Basal cell carcinoma -- This is the most common type of skin cancer . It is usually pearly or reddish, but sometimes it has brownish pigmentation which may allow it to be mistaken for a freckle.
A warning
Anyone who has one or more pigmented spots of which they are not certain should have their physician or dermatologist evaluate them, if only for peace of mind. Even verbal descriptions and photographs cannot convey enough information for satisfactory self-diagnosis. As always, it is better to be safe than sorry.
How can freckles be prevented?
Many people would rather not develop freckles or, if they already have freckles, they would like to get rid of them.
Freckle prevention is obviously better than developing them and then needing to treat them. Therefore, anyone with an hereditary tendency to freckle -- who freckles easily -- should wear sunscreen whenever appropriate and also minimize their sun exposure. The aim here is twofold -- to suppress their tendency to produce freckles and, much more importantly, to reduce their risk of developing skin cancer .
The tendency to freckle easily goes along with the tendency to sun-sensitive skin cancer. Freckles are a warning to people who have them that their skin is highly vulnerable to sunburn and to skin cancer.
How can freckles be treated?
To treat freckles that are already present, several safe and effective methods are available:
- Bleaching creams -- Products containing hydroquinone and kojic acid can be used after consultation with doctor. Higher concentrations of hydroquinone (over 2%) are also useful. These products can lighten freckles if they are applied consistently over a period of months.
- Tretinoin -- Sometimes used in conjunction with other bleaching creams, tretinoin (vitamin A acid, Retin-A) also helps to make freckles lighter when applied over a period of time.
- Cryosurgery -- A light freeze with liquid nitrogen can be used to treat freckles.
- Laser treatment -- Several lasers, especially ones that produce a green light, can lighten and eliminate freckles safely and effectively. Like cryosurgery, this is a simple and safe procedure with a high success rate and a low risk of scarring.
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Moles
Moles are growths on the skin that are usually brown or black. Moles can appear anywhere on the skin, alone or in groups.
Most moles appear in early childhood and during the first 20 years of a person's life. Some moles may not appear until later in life. It is normal to have between 10-40 moles by adulthood.
As the years pass, moles usually change slowly, becoming raised and/or changing color. Often, hairs develop on the mole. Some moles may not change at all, while others may slowly disappear over time.
What Causes a Mole?
Moles occur when cells in the skin grow in a cluster instead of being spread throughout the skin. These cells are called melanocytes, and they make the pigment that gives skin its natural color.
Moles may darken after exposure to the sun, during the teen years, and during pregnancy.
Types of Moles
• Congenital nevi are moles that appear at birth. Congenital nevi occur in about one in 100 people. These moles may be more likely to develop into melanoma (cancer) than are moles that appear after birth. If the mole is more than eight inches in diameter, it poses a significant risk of becoming cancerous.
• Dysplastic nevi are moles that are larger than average (larger than a pencil eraser) and irregular in shape. They tend to have uneven color with dark brown centers and lighter, uneven edges. These moles tend to be hereditary (passed on from parent to child through genes). People with dysplastic nevi may have more than 100 moles and have a greater chance of developing malignant (cancerous) melanoma. Any changes in a mole should be checked by a dermatologist to detect skin cancer.
How Do I Know if a Mole Is Cancer?
Most moles are not dangerous. The only moles that are of medical concern are those that look different than other existing moles or those that first appear after age 20.
If you notice changes in a mole's color, height, size or shape, you should have a dermatologist (skin doctor) evaluate it. You also should have moles checked if they bleed, ooze, itch, appear scaly, or become tender or painful.
If your moles do not change over time, there is little reason for concern. If you see any signs of change in an existing mole, if you have a new mole, or if you want a mole to be removed for cosmetic reasons, talk to your dermatologist.
The following ABCDEs are important characteristics to consider when examining your moles. If a mole displays any of the signs listed below, have it checked immediately by a dermatologist. It could be cancerous.
• Asymmetry. One half of the mole does not match the other half.
• Border. The border or edges of the mole are ragged, blurred, or irregular.
• Color. The color of the mole is not the same throughout or has shades of tan, brown, black, blue, white, or red.
• Diameter. The diameter of a mole is larger than the eraser of a pencil.
• Elevation. A mole appears elevated, or raised from the skin.
Melanoma is a form of skin cancer. The most common location for melanoma in men is the back and in women, it is the lower leg. Melanoma is the most common cancer in women ages 25 to 29.
How Are Moles Treated?
If a dermatologist believes a mole needs to be evaluated further or removed entirely, he or she will either remove the entire mole, or first take just a small tissue sample of the mole to examine thin sections of the tissue under a microscope (a biopsy). This is a simple procedure. (If the dermatologist thinks the mole might be cancerous, cutting through the mole will not cause the cancer to spread.)
If the mole is found to be cancerous, and only a small section of tissue was taken, the dermatologist will remove the entire mole by cutting out the entire mole and a rim of normal skin around it, and stitching the wound closed. |
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Skin Tags
What is a skin tag?
A skin tag is a common, benign condition which consists of a bit of skin that projects from the surrounding skin and may appear attached to the skin.
Skin tags can vary quite a bit in appearance. They may be smooth or irregular, flesh colored or more deeply pigmented, and either simply be raised above the surrounding skin or have a stalk (a peduncle) so that the skin tag hangs from the skin.
Where do skin tags occur?
Skin tags can occur almost anywhere there is skin. However, favorite areas for tags are the eyelids, neck, armpits (axillae), upper chest, and groin.
Who tends to get skin tags?
They are much more common with age beginning in middle age and they tend to be somewhat more prevalent in women than men.
Is a skin tag a tumor?
Yes, it is in the sense that it is a growth. However, it is a benign (harmless and not a malignant) condition.
What does a skin tag look like under a microscope?
The outer layer of the skin (the epidermis) shows overgrowth (hyperplasia) and it encloses an underlying layer of skin (the dermis) in which the normally-present collagen fibers appear abnormally loose and swollen.
What problems do skin tags cause?
Usually none. This tiny skin growth generally causes no symptoms unless it is repeatedly irritated as, for example, by the collar or in the crotch.
How are skin tags treated?
In cases in which a skin tag is irritated or cosmetically unwanted, treatment may be done by freezing the tag with liquid nitrogen, or cutting off (excising) the tag with a scalpel or scissors.
Is there another medical name for a skin tag?
A skin tag is medically also termed a cutaneous papilloma or an acrochordon. However, a skin tag is best known as a skin tag.
- A skin tag is a common but harmless skin growth.
- Skin tags are frequently found on the eyelids, neck, chest, armpits, and groin.
- Treatments include freezing, or cutting off.
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Seborrheic Keratoses
Seborrheic keratoses are brown or black growths usually found on the chest and back, aswell as on the head. They originate from cells called keratinocytes. As they develop, seborrheic keratoses take on a warty appearance. They do not lead to skin cancer.
What Causes Seborrheic Keratoses?
The cause of seborrheic keratoses is unknown. They are seen more often as people get older.
How Are Seborrheic Keratoses Treated?
Seborrheic keratoses are benign (not harmful) and are not contagious. Therefore, they don't need to be treated.
If you decide to have seborrheic keratoses removed because you don't like the way they look, or because they are chronically irritated by clothing.
How are they treated?
Creams, ointments, or other medication can neither cure nor prevent seborrheic keratoses. Most often seborrheic keratoses are removed by cryosurgery, curettage, or electrosurgery.
Cryosurgery — liquid nitrogen, a very cold liquid gas, is applied to the growth with a cotton swab or spray gun to “freeze” it. The keratosis usually falls off within a few weeks.
Curettage — the keratosis is scraped from the skin. An injection or spray is first used to anesthetize (numb) the area before the growth is removed (curetted). No stitches are necessary.
Electrosurgery — the growth is anesthetized (numbed) and an electric current is used to burn the growth which is then scraped off. |
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Laser for Growths on the Skin
Carbon Dioxide Laser Skin Resurfacing
Carbon dioxide lasers have been in use for many years to treat different skin conditions. A new generation of carbon dioxide lasers use very short pulsed light energy (ultrapulsed) or continuous light beams that are delivered in a scanning pattern to remove thin layers of skin with minimal heat damage to the surrounding structures. These lasers are used to treat wrinkles , scars, warts, moles, skin tags, freckles, linear epidermal nevi ( birthmarks ) , rhinophyma (enlarged oil glands on the nose), and other skin conditions.
Carbon dioxide laser resurfacing is usually performed on an outpatient basis, using local anesthesia in combination with orally- or intravenously-administered sedative medications. The areas to be treated are numbed with a local anesthetic. (General anesthesia may be used when the entire face is treated.) A partial-face laser abrasion takes 30-45 minutes, and the full-face treatment takes 1-1/2 to 2 hours.
Following the laser resurfacing procedure, a special dressing is applied to the treatment sites for 24 hours. The areas usually heal in 10-21 days, depending on the nature of the condition that was treated.
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