These are abnormal scars following any injury, including surgery, burns and earlobe piercing.

How do they form?

The skin has a microscopic surface layer, the epidermis and a deeper layer, the dermis.

The epidermis is uniform in thickness (except in the palm of the hand and the sole of the foot) while the dermis varies in thickness, ranging from 1 mm in the eyelid, 2mm on the cheek and
5mm on the back.

The dermis has an ExtraCellular Matrix (ECM) which is a scaffolding to give strength to the dermis.

To form a scar, there has to be damage to the ECM. The scar is part of the repair process following an injury and this gives strength to the repaired area.  Unfortunately, this process of repair can sometimes be too strong, resulting in a hypertrophic or keloid scar.

(The epidermis, with no ECM, does not form scars).

Management

Prophylaxis and prevention give the best results!.

The process of scar formation

Scar formation is part of the healing process , to help regain strength (tensile strength). There is an initial rapid phase, followed by a slower but longer phase, to make a total of three months, after which there is tissue maturation and remodelling for a further three months

Abnormal scar formation can happen in any phase of healing.

Prophylaxis involves good planning about the intended surgery, placement of scars and post-operative scar management including compression therapy.

Compression Therapy involves lower pressure, probably constant, compression. For larger areas, a compression garment is used. For smaller areas, custom-made compression splints work well, including custom made ear rings for earlobe keloids.

For other parts of the ear, silastic splints are made for an exact fit.

Silicon gel usage is also part of the treatment.

Treatment

These scars may cause pain and itchiness , in addition to the change in appearance.

Pain and itchiness are treated with regular steroid injections or with steroid impregnated tape.

In a keloid scar causing disfigurement, the scar is reduced to make the affected area look near-normal in contour, and this is followed up with compression splints.

For earlobe keloids, the ear rings are made before the surgery, using the unaffected other side as a template.

For other areas, like the helical (margin) part of the ear, a silicon splint is custom-made once the wound is healed

Treatment will be for at least three months, but may be for longer sometimes.

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The initial step in the treatment of a skin cancer is to confirm the diagnosis.

Quite often, this is a clinical decision made after examining the affected area with magnification and good lighting.

Sometimes, a biopsy is done, where a small section of the cancer is removed and sent for study by a Pathologist.

Appropriate treatment is then planned, and this may be with the Carbon Dioxide laser for superficial cancers, or excision (removal) with a knife for deeper cancers.

Reconstruction of the treated area, to leave it looking as near-normal as possible and to preserve function, is often necessary and is usually carried out at the same time as removal of the cancer.

Residual or Recurrent Skin Cancers

The treatment of residual skin cancers, where initial treatment was inadequate and where there is persistence of cancer, and recurrent cancers, where the cancer re occurs after previous treatment, is more difficult.

In a significant percentage of patients, surgery is done in a staged fashion, where excision is done to confirm adequacy of cancer removal and followed up by reconstruction with skin grafts or flaps (skin and fat) and sometimes with additional material such as cartilage from the ear or nose.

Occasionally, a frozen section examination is done, when a Pathologist examines the tissue removed while the patient is still having the surgery.

The need for comprehensive care in skin cancer treatment

There is a lot more to Skin Cancer treatment than just the actual removal of tumour. Accurate diagnosis, adequate removal, appropriate reconstruction, and proper long-term follow-up care is needed.

Preservation of function and appearance (form) takes a while to be established, due to the way tissue heals and matures, and hence scar management and long-term follow-up  are important parts of treatment.

There may also be a need for more treatment in the form of surgery, radiotherapy or chemotherapy.

The above expert care and management, including reconstruction to maintain function and form is available at the plastic cosmetic laser surgery centre with care provided by Dr Arianayagam and his team.

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Capsular contracture
As the breast implant has an outer silicon shell, a relatively inert material, the breast implant is not rejected, but the body responds by putting an outer layer around it called the capsule.
However, this protective capsule can undergo contracture and the problems it causes are well documented.

BIA-ALCL (Anaplastic Large Cell Lymphoma)
This is a more recently recognised problem, over the last 7 to 8 years.
While a proportion of women have swelling and pain of a breast a few years after augmentation, investigations have not shown any problems in most of them, and symptomatic treatment is all that is required.
However, in a very small proportion of patients, less than 1500 over the last 7 to 8 years, removal, and testing of the fluid collection around the enlarged breast has shown the presence of a CD 30 receptor protein, which is diagnostic for ALCL.
A peculiar feature is that this problem has only been seen in textured implants.
Textured implants help shaped implants to be held in the right position.
As a result of this problem, which needs surgical correction involving removal of the implant and surrounding capsule, there has been a rapid shift to using only round smooth implants.

BII (Breast Implant Illness)
Some patients with breast implants have, over the years, complained of difficult to explain, vague systemic symptoms, such as excessive tiredness, anxiety, depression, cognitive difficulties, myalgia, and skin rashes.
For quite a while, this problem was not well understood and women who exhibited these symptoms had difficulties conveying their concerns to their treating physicians.
After a lot of effort from patients and with the help of sympathetic surgeons who responded to the distress of their patients, a few women had their implants removed and in some the effect was a very impressive relief of symptoms!
Though the medical establishment took a while to be convinced, social media, with the instant access it provided, helped more women to get the treatment they deserved, with a good percentage showing significant relief of their symptoms
By 2019, the US Food and Drug Administration (FDA) and the major Plastic Surgery Societies accepted that there seemed to be an inflammatory or autoimmune response in some women with breast implants which was causing a range of symptoms that suggested BII (breast implant illness) and that a proportion of patients had relief with removal of the implants. The problem was the lack of well-documented studies to confirm this trend.

In March 2022, published online in EPlasty is a paper entitled “Breast Implant ilIlness: Treatment using Total Capsulectomy and Implant Removal” by Stephen E. Metzinger MD et al.
Dr Metzinger, the lead author is a Plastic Surgeon from the Division of Plastic and Reconstructive Surgery of the Tulane University School of Medicine in New Orleans.
This was a retrospective cohort study for the period 2016 to 2020, with a total of 200 patients who presented with mastodynia and capsular contracture, with or without extra mammary symptoms, after cosmetic breast implant surgery.
The surgical treatment was an enbloc removal of implant and capsule.
ESPECIALLY IMPORTANT WAS THE FACT THAT ALL SURGERY WAS DONE BY Dr METZINGER
96% of patients reported improved or complete resolution of their systemic symptoms!
A positive microbial culture was found in 68.5% of patients
Average follow-up time was five months.

CONCLUSION
Enbloc removal of implant and capsule dramatically improves symptoms of breast implant illness.

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Sometimes this healing results in a poor outcome.

A good example would be a burn of skin over the elbow – the quickest way of healing by the body would result in contracture of the elbow due to healthy edges of the skin pulling together. The better outcome would be to splint the elbow to hold it out, to enable healing by epithelialisation and wound contraction which would leave the elbow with a full range of movements.

If injury is very specific and controlled, the resultant healing gives a very good outcome.

High Intensity Focussed Ultrasound (HIFU) works in this way to tighten skin. While this is not an alternative to surgical treatment, it is useful where the problem is a mild one, such as in slight slackness of skin of the neck, or where there is asymmetry as in one eyebrow being lower than the other.

In both of the above circumstances, HIFU gives the necessary improvement without any surgical scar.

It works by creating small, controlled areas of injury separated by normal tissue.

These areas are created in the deep, intermediate and superficial areas of the dermis (the deeper part of skin which is beneath the superficial layer of skin, the epidermis) by the use of HIFU of different wavelengths.

Two sessions of treatment is required, four months apart.

Eyebrow Asymmetry (right lower than left)

Neck Skin Slackness

The post SKIN TIGHTENING WITHOUT SURGERY appeared first on PCLS Coffs Harbour.

However, in Mr JG, a 56 year old man, who was a regular smoker, the lesion on his lower lip was very extensive.

Cancer marked out with usual resection margins (Figure 1)

The standard treatment would have involved extensive resection (removal) of muscle and mucosa.

This is possible and often gives a good outcome, as seen in Miss KW, a 55 year old lady with an extensive skin cancer involving the upper lip and cheek:

Figure 2 – Before Surgery

Figure 3 – During Surgery

Figure 4 – During Surgery

Figure 5 – Four years later

 

Figure 6 – Four years later

In Mr JG, as the lesion was much larger, it was decided to treat the problem with a different approach.
The tumour was excised including mucosa and all submucosal tissue, down to the muscle layer.
At surgery, it was clear the tumour was still in the deeper mucosa (deep papillary dermal layer) and had not gone to the muscle layer.

The large mucosal defect was repaired by extensive mobilisation of the vestibular mucosa (the inner lining of the lower lip) while the muscle layer was preserved.

The pathology report confirmed complete removal of tumour.

Figure 7 – After surgery

Figure 8 – After surgery

Figure 9 – After surgery

Figure 10 

Figure 11 

 

Skin cancers of the face are difficult to treat – early treatment is best but if the problem is extensive, an expert Plastic Surgeon often helps in achieving a good outcome.

The post SKIN CANCER OF THE LIP – AN UPDATE appeared first on PCLS Coffs Harbour.

Breast Implants, since their initial development in 1961 by Cronin and Gerow with the help of Dow Corning, have made a great impact on the lives of many women both through breast augmentation for volume increase and reconstruction for rehabilitation of women after mastectomy for cancer.

Since the initial use in a patient for augmentation in 1962, there have been gradual improvements in the style and quality of the implants.

Generation 1

The initial implants were made of a silicon-rubber envelope filled with viscous silicone gel. 

Generation 2

In the 1970s, a number of improvements were made.

Initially, a thinner gauge of implant shell and filler gel of low cohesion were developed to give a more realistic shape, size and consistency.  However, there were problems with fragility, rupture, bleed and capsular contracture that occurred.

A further improvement was made by the use of a polyurethane foam coating of the shell, which appeared to reduce capsular contracture.  There were some concerns about the risk from TDA. (2,4 – Toluenediamine), a carcinogenic byproduct of the chemical breakdown of the polyurethane foam but eventually this was considered too small a risk to be of any concern.

Further improvement was a double lumen implant, in which an inner silicone gel implant was contained in an outer saline implant.  However, due to the high device failure rate, the double lumen implant did not gain much popularity.

Generation 3 and 4

Further improvements were made with elastomer coated shells to reduced bleed, thicker increased  cohesion filler gels and shaped anatomical models with textured surfaces to avoid implant rotation.

Generation 5

Since the mid-1990s, implant shells have been made of semi-solid gel to reduce bleed and migration of gel.

Summary of Developmental Changes

The outer shells have become stronger and the silicone gel used for the filling has become more cohesive. 
The implants are available in round and anatomical shapes, with the former being available in round or textured surfaces while the latter is available only with textured surfaces to overcome the risk of implant rotation.
There is also a greater availability of shapes and projections, to customize the choice of implant to suit the patient best.

Problems and Complications With The Use of Breast Implants

The majority of patients have good outcomes with the use of breast implants.

Some patients have relatively minor problems, which are well tolerated and needing no further treatment. However, in a small proportion of patients, the problems can become more troublesome and needing further treatment. The major issue is often the problem of capsular contracture.

Silicone, despite being a foreign matter, appears to be very well tolerated by the body, probably due to the material being a relatively inert one.  However, a very rapid response from the body to an implant is the development of a tissue capsule around the implant to separate it from the breast cavity.  These tissue capsules are capable of contracting around the implant.

Capsular contractures are graded according to the Baker – Gordon Classification:

Grade 1 – the breast looks and feels normal

Grade 2 – the breast looks normal but feels slightly firm

Grade 3 – the breast looks abnormal and feels firm

Grade 4 – the breast looks abnormal, is painful and interferes with the activities of daily living.  Fortunately, approximately 80% of patients with implants fall into grade 1 – 3 and require no further treatment.

Of the 20% with grade 4 capsular contractures, about half can be converted to grade 3 with increasing the size of the breast cavity and reducing the size of the implant.

The remaining patients in whom there is the persistence of grade 4, have little choice but to have the implant removed permanently as the body reaction suggests that there is a strong reaction provoked by the silicone implant and persisting with this stimulus might lead to an autoimmune problem.

Breast Implant Illness (BII)

While capsular contractures and gel leak, bleed and implant rupture are well recognized complications, there is increasing evidence, mainly anecdotal, that a proportion of patients with breast implants exhibit troublesome medical symptoms which are difficult to explain but have gained significant relief with the removal of these implants.

For a long time, these symptoms, while present in a proportion of patients with implants, have not been recognized by many in the industry and profession. There has been a change recently and in May 2019, the FDA released a statement it was taking steps to better characterize “Breast Implant Illness (BIA)”  and its risk factors, and for implant recipients to have all of this information available to them.

BIA-ALCL

While information was being gathered on BII, a new problem appeared when it was noted that some women were presenting with swollen, tender and enlarged breasts on one side, presence of a lump in the breast or armpit, usually about 5 – 7 years after breast augmentation.  Further investigation showed the presence of a fluid collection around the implant. 

Examination of the lump in the breast or armpit or of the fluid collection in a small proportion of patients showed the presence of Anaplastic Large Cell Lymphoma, which has now been named Breast Implant Associated – Anaplastic Large Cell Lymphoma (BIA-ALCL).

First seen in 1997, over the last 5 – 7 years, there have been about 900 patients who have been diagnosed with BIA-ALCL.  A feature common to all patients is that they received textured implants.  Treatment will involve PET/CT scans to check if there is spread elsewhere in the body.

After evaluation by an Oncologist for staging of the disease and treatment planning, the implant along with the capsule is removed.

Patients with advanced disease may require treatment with chemotherapy or in rare cases radiation therapy.

Changes To The Practice Of Use Of Breast Implants

There has been a worldwide recall / cessation of sale of textured breast implants.

Many surgeons, including myself, now restrict ourselves to the use of round, smooth implants.

More work is being done to develop tests to check potential allergy and reaction to silicone amongst patients needing breast implants.

In addition, greater investigation needs to be done to see if there are allergic or autoimmune patterns in a patient’s history.

In addition, patients need to be fully updated on the above problems noted with the use of breast implants, to help them make informed decisions about going down this path.

References

1 – Special Report:  Breast Implant Illness and BIA-ALCL.  www.breastcancer.org (16.9.2020)

2 – What is BIA-ALCL?  www.breastcancer.org (16.09.2020)

3 – What is Breast Implant Illness?  www.breastcancer.org  (16.09.2020)

4 – Frequently Asked Questions About Breast Implant Illness and BIA-ALCL  www.breastcancer.org (16.09.2020)

5 – Breast Implant Patient Informed Consent Checklist and Black Box Warnings – Developed by the Breast Implant Working Group

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What is the secret?
A thorough understanding of the structure of skin is a requirement.

The skin is made up of a microscopic superficial layer called the epidermis and a deeper thicker layer called the dermis.

The epidermis consists of mainly basal cells which are the basic skin cells, and melanocytes which produce pigment to protect the skin cells.

The dermis has a scaffolding called the extracellular matrix (ECM) on which are deposited the myriad structures and cells of the dermis. The ECM gives strength to the dermis but also the ability to form scars as a result of injuries such as surgery.

The epidermis on the other hand does not have an ECM and hence does not cause scarring with injuries; instead, it heals by regeneration.

Hence, to have scarless surgery, the injury needs to be limited to the epidermis.

Below are examples of a patient with intradermal naevi treated with the carbon dioxide laser with very good results, showing adequate removal of the lesions and with no scar production.

The intradermal naevus is a mole which appears clear, originating in the deep dermis and slowly increasing in size to finally project through the epidermis.

The Carbon Dioxide laser is a high precision instrument which gives us the ability to remove the microscopic epidermis, and with it, the epidermal part of the intradermal naevus.

As the epidermis heals by regeneration, no scar is produced, as shown in the before and after photographs below.

The dermal component of the intradermal naevus is left in situ.

Long-term follow-up confirms the lack of recurrence of this problem with this treatment.

An extreme version of this treatment is used in carbon dioxide full-face resurfacing where the skin of the entire face is treated with the carbon dioxide laser for exceptional results.

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There is an urgent need for perspective in this matter. About 1.5 million women worldwide have breast augmentation annually while the total number of women diagnosed with the above problem over the years is only approximately 800.

Based on the above facts and with the benefit of many years of experience, my advice is:

1. Use only smooth breast implants as no reported cases of BIA – ALCL involves a smooth implant.
2. It takes about seven years before problems occur, so do not rush into treatment.
3. Pain, swelling and fluid collection in the implanted breast is not always due to BIA – ALCL.
4. If you are asymptomatic, don’t do anything.
5. If you are symptomatic, get the implants removed and replaced with smooth, round implants.
6. If you are diagnosed with the problem, seek treatment with a Plastic Surgeon with expertise in this matter

Since August 2018, I only use smooth, round gel implants.

If you have a problem or concerns, please come and see me for assessment, advice and if necessary, treatment.

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This method of hernia repair often allows some excess skin and fat to be removed at the same time. 

If you have an abdominal hernia, either spontaneous or incisional, please call for an appointment.

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In addition, the further development of textured surfaces and the “teardrop” or bio dimensional shapes for these implants have further improved the outcomes.

The textured surface allows tissue ingrowth from the body capsule around the implant into the surface of the implant which allows for good positioning and fixation of the implant.

In addition, the high cohesive nature of the silicone gel used adds great safety as the implant does not migrate even if there is a rupture of the textured capsule around the gel.

However, there are some recent events which are causing a re-think on the choice of implants.

First seen in 1997, over the last 5 to 7 years, there have been patients who have noted swelling and pain in the breasts, or from one side, about 6 to 7 years after breast augmentation.

The use of ultrasound examination shows the presence of a collection of fluid (seroma) at the base of the implant.

Further examination of this collection with immunohistochemistry has showed the presence of CD30, leading to a diagnosis of BIA – ALCL (Breast Implant Associated – Anaplastic Large Cell Lymphoma).

Recent figures show about 790 women who have presented with this problem.

A very distinctive feature in these women is that almost all patients have had textured implants.

While there is a good availability of smooth surfaced implants, these do not work for the bio dimensional shape as the smooth implants do not get fixed to tissue.

As a result, in the interests of patient safety, I have stopped the use of textured implants and instead use only high cohesive smooth surfaced round gel implants.

Before and after 8 months

Before and after 18 months

Before and after 3 years and 3 months

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