Tuesday, June 26, 2012


Smoking Increases Risk for Cutaneous Squamous Cell Carcinoma

Add cutaneous squamous cell carcinoma to the list of cancers caused by smoking.
Jo Leonardi-Bee, PhD, of the U.K. Centre for Tobacco Control Studies at the University of Nottingham in England, and colleagues reviewed findings of 25 studies from 11 countries across four continents.
They found that smoking increased risk for cutaneous squamous cell carcinoma (SCC) by 52%. This risk was most pronounced among current or ever smokers, with smaller effect sizes occurring in former smokers. Smoking did not affect risk of basal cell carcinoma or non-melanoma skin cancers. Their findings appear online in the Archives of Dermatology.
“This study highlights the importance for clinicians to actively survey high-risk patients, including current smokers, to identify early skin cancers, since early diagnosis can improve prognosis because early lesions are simpler to treat compared with larger or neglected lesions,” study authors write.
In an editorial accompanying the new study, dermatologists Joris A. C. Verkouteren, MD, and Tamar Nijsten, MD, PhD, from Erasmus Medical Center in Rotterdam, the Netherlands, agree that dermatologists must step up and inform patients about the cutaneous adverse events of smoking.
“We believe all this can be done in a busy dermatology clinic,” they write. “In contrast to several risk factors of SCC, including prior UV radiation exposure, smoking is a modifiable factor. Thus, active risk reduction by smoking cessation is possible,” they write. “Furthermore, physicians could make use of the current cancer experience in motivating patients to discontinue smoking, which has many additional important health benefits.”
[Source: Archives of Dermatology]


More than Skin Deep: Psoriasis Linked to Type 2 Diabetes Risk

Psoriasis may be a risk factor for Type 2 diabetes, new research suggests.
The study, which appears online in the Archives of Dermatology, adds to a growing body of evidence that suggests psoriasis is not just skin deep. The inflammatory skin condition has been linked to heart disease, stroke, and some cancers.
Among 108,132 patients with psoriasis with 430,716 patients without psoriasis, risk of developing type 2 diabetes among 1,000 patients with psoriasis per year is 0.9 extra cases overall. Specifically, there will be 0.7 extra cases of diabetes in those with mild psoriasis, and 3.0 cases in those with severe psoriasis, the study showed.
The study also looked at whether patients with diabetes and psoriasis were more likely to receive prescription medication for diabetes. There were no difference in the use of oral hypoglycemic agents or insulin among patients with mild psoriasis. Patients with severe psoriasis, however, were more likely to be prescribed oral hypoglycemic agents and had a trend toward being more likely to be prescribed insulin, the study showed.
“The data from this study suggest that psoriasis is a risk factor for the development of [Type 2 diabetes] and that this relationship is dose dependent, with severe psoriasis conferring a higher risk than mild psoriasis,” the authors write. “Mechanistically, this relationship may be driven by chronic inflammation because both psoriasis and [type 2 diabetes] are associated with elevated levels of TH1-driven inflammatory markers, and because several studies have pointed to endogenous insulin resistance in patients with psoriasis.”
[Source: Archives of Dermatology]


UK Report: PIP Breast Implants Not Toxic, But Have High Rupture Rates

PIP breast implants do not cause cancer, according to a new study by the British Department of Health.
These implants—which were filled with industrial-grade silicone—are not toxic, but they do have higher-than-average rupture rates when compared with other silicone gel-filled implants. If and when the PIP implants rupture, women may suffer irritation and swelling of the lymph nodes, but will not have any significant lasting health effects.
An estimated 300,000 women in 65 countries received breast implants from the now defunct company, Poly Implant Prothèse (PIP). The implants were banned in 2010, and the company went bankrupt later that year. These implants were never approved for sale in the US, but several US doctors have removed PIP implants from women who received them in other countries.
The new report was conducted by Bruce Keogh, the medical director of Britain's National Health Service. He analyzed data on 240,000 breast implants from different manufacturers given to 130,000 women in England as well as information from other countries including France and Australia.
The British Association of Aesthetic Plastic Surgeons (BAAPS) lauds the new report.
"Despite rigorous testing showing no long-term danger to human health from the individual chemicals in the gel, the fact remains that PIPs are significantly more likely to rupture and leak and, therefore, cause physical reactions in an unacceptable proportion of the patients, says BAAPS President Fazel Fatah in a press release. “Any and all women should be given the option to discuss their individual needs and should be fully supported by their provider whatever their choice, removal or monitoring, [and] we fully support the report's conclusions that all providers who implanted PIPs have a responsibility to proactively share with their patients objective and up-to-date information about the risks to their health so they can make an informed decision on the removal of their implants."
Affected countries differ in how they treat women with the PIP implants, and who should foot the bill. German medical groups recommended that women seek nonurgent removal of the implants. France has said it will pay for some 30,000 French women to have their PIP implants removed. The UK government has agreed to remove any implants put in by the National Health Service, but said women who had the surgery done privately should have those clinics remove their implants.

Sunday, June 24, 2012


DANA POINT, CALIF. – A growing body of evidence-based research supports the efficacy of cryolipolysis for noninvasive fat reduction in the abdomen and flanks.

At the Summit in Aesthetic Medicine sponsored by Skin Disease Education Foundation (SDEF), Dr. Lawrence S. Bass highlighted results from several recent studies that support its use.
In the first study, presented by Dr. Christine C. Dierickx at the 2012 American Society for Laser Medicine and Surgery (ASLMS) meeting, researchers cataloged side effects in a phone review conducted with patients 1 month following cryolipolysis. All interviewed patients reported erythema that lasted about 1 hour and paresthesia that lasted for up to 1 month after treatment. Other reported side effects were ecchymosis (4%), vasovagal reactions from treatments on the abdomen (2.1%), induration/edema (0.9% and lasting 2-5 weeks), and severe pain (0.6% and lasting for a maximum of 1 month).
A separate study, presented by Dr. Gerald Boey at the 2012 ASLMS meeting, found an amplified fat reduction when concomitant massage was used. For the trial, 10 patients underwent 2 minutes of massage to one side only after cryolipolysis treatment. Ultrasound evaluation revealed that an additional 68% reduction in fat was achieved on the massaged side.
A safety and efficacy trial, carried out at 16 centers and involving 314 patients, was presented by Dr. A. Jay Burns at the 2010 ASLMS meeting. The study found no serious side effects and no skin damage or pigment change from the procedure. Minor side effects included transient bruising, minor pain, reduced sensation, erythema, and edema – all of which resolved spontaneously.
Of 41 patients in the study who underwent ultrasound measurement, the average reduction in fat was 21% after a single procedure. "That’s a consistent number you see in many studies," said Dr. Bass, of the plastic surgery department at New York University School of Medicine.
In a separate study also presented at the 2010 ASLMS meeting, researchers led by Dr. Ivan A. Rosales-Berber investigated the effect of consecutive cryolipolysis treatments separated by 2-3 months. The second treatment resulted in a similar proportion of fat reduction as the first treatment (14.6% vs. 16.5%, respectively).
Three months after the second procedure, the fat layer reduction exceeded 25%. This "means that there is repeatability [with cryolipolysis]," Dr. Bass said. "That’s important, because unfortunately a lot of patients have more than one body contouring emergency in their lives."
An earlier published study determined that cryolipolysis associated with modest reversible short-term changes in peripheral nerve function (Aesthetic Plast. Surg. 2009;33:482-8). Ten patients underwent a thorough neurological evaluation at baseline and weekly after the procedure. All patients returned to baseline peripheral nerve function in an average of 3.6 weeks. The study also found that mean fat reduction by ultrasound was 20.4% at 2 months and 25.5% at 6 months. "Even though we think it takes about 90 days for this whole apoptotic process to resolve, there may be something ongoing, or some tissue consolidation taking place for a longer period of time, allowing patients to continue to improve," Dr. Bass noted.


DANA POINT, CALIF. – No longer just a pipe dream, a novel injectable treatment effective at reducing fat is approaching the end of the drug development process.

The product is a non–animal derived, pharmaceutical grade sodium deoxycholate that "acts much like a detergent. It attacks the cell membranes of fat, disrupting and disintegrating its membranes. Thereafter, fat cell contents are released and the subsequent host response, including inflammation, macrophage scavenging, and subclinical fibrosis, may confer a long-lasting fat-removal effect. It doesn’t shrink the fat cell; it ablates the fat it encounters," said, Dr. Adam M. Rotunda.
Phase III trials of an injectable form of sodium deoxycholate for the reduction of submental fat have begun in the United States, building on the previous success of four phase I, three phase II, and two phase III European studies of the product, known as ATX-101, noted Dr. Rotunda at the Summit in Aesthetic Medicine sponsored by the Skin Disease Education Foundation (SDEF).
In the 1990s, compounded phosphatidylcholine/deoxycholate injections (PC/DC), or lipodissolve, caused harm to some patients because "essentially everything about that experience was wrong: the wrong dose (too much volume, too high concentration); wrong depth (injections at times were too superficial. For example, cellulite, which was erroneously believed to improve from the injections, was injected intradermally); wrong indication (injections in places that shouldn’t have been injected); and wrong formulation," said Dr. Rotunda, who practices dermatology in Newport Beach, Calif. "These compounds were [derived] from animal sources and their sterility and purity could be called into question."
As a result, the FDA and other regulatory agencies around the world warned against or banned the use of unapproved PC/DC for aesthetic purposes. But in 2003, sodium deoxycholate was identified as the major component producing fat cell lysis in compounded PC/DC formulations, said Dr. Rotunda, who is also with the department of dermatology at the University of California, Los Angeles. "It’s taken many years to get that message across," he said.
ATX-101, which is being developed by Kythera Biopharmaceuticals, "is very different from the DC in compounded formulations, which was derived from cow bile," he said. "ATX-101 is being studied for very small volumes of fat relatively small for the submental area, which is really an ideal area to observe the desired effect of this product."
Phase I histology studies revealed that ATX-101 causes rapid adipocytolysis on day 1. On day 28 "there’s septal thickening and macrophage infiltration, which removes cellular debris and triglycerides, cleared via the lymphatic system," Dr. Rotunda said, adding that before and after MRIs have quantitatively confirmed the volume reductions.
Tissue surrounding the fatty treatment area, he continued, "has relatively high protein content. This protein (such as albumin) binds and inactivates deoxycholate, making subcutaneous injections relatively safe and fat specific. There’s an inverse relationship: the higher the protein content of certain tissue, such as muscle, tendon, and dermis, the lower the lytic activity of the deoxycholate. Less activity means less damage to that tissue. In fat, however, we want maximal damage, and it works out well because fat has relatively low protein content."

Wednesday, June 20, 2012


Specialized stem cells from fat strengthen bones

Researchers at the University of California, Los Angeles, using fluorescence-activated cell sorting, have isolated a type of stem cell from fat tissue that is proving effective in enhancing bone formation. The cells, known as human perivascular stem cells, have proved superior to stromal vascular cells by differentiating into bone more easily to increase bone production. DoctorsLounge.com/HealthDay News (6/15)


Women who receive liposuction to remove subcutaneous fat must exercise after surgery to avoid gaining visceral fat deep in their abdomens, which can be a long-term health risk, according to a study of 36 Brazilian women ages 20 to 35. Liposuction may "trigger a compensatory increase of visceral fat, which is effectively counteracted by physical activity," researchers reported. The New York Times (tiered subscription model)/Well blog (6/13), Time.com/Healthland blog (6/15)

Sunday, June 10, 2012


How many times a week do I get asked by my patients how to get rid of the "dark circles" under their eyes? The term is a catch-all used by physicians and patients to refer to problems that have a vast range of genetic, environmental, and skin-related causes. It is a common and frustrating problem, with little structure in its definition and few full-proof treatments. Below is my proposed classification system for the definition of dark circles and clinical pearls for their treatment. Most patients, however, have a combination of each type and multifactorial causes that need to be addressed.

Infraorbital fat pad protrusion. Also known as "eye bags."
Blepharoplasty is the best, and for now the only, solution for severe fat pad prominence. Referral to a board certified plastic surgeon or dermatologic surgeon is recommended.
If the protrusion is mild and tear troughs are prominent, fillers may be injected into the tear trough area to help mask the protrusion. My favorites for this area are hyalauronic acid fillers like Juvéderm Ultra or Restlyane, sometimes double diluted with normal saline or injected with a 32-gauge needle.

For loose skin with "bags," radiofrequency lasers can provide some benefit. The Thermage eyelid tip produces results over 3-6 months, with repeat treatment possible at 6 months. I always advise patients that this treatment is not a replacement for surgery but can provide some benefit in those who are not surgical candidates or who do not want surgery.

Infraorbital edema. Also known as "puffiness."
The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying or water retention from high blood pressure or eating high sodium foods are some of the reasons the loose, thin epidermis becomes edematous.
Treat seasonal allergies with over-the-counter allergy medications or prescription medications for resistant allergies or possible sinus infections.
I advise patients to switch their sleep position. Sleep position can be contributing to undereye bags through gravity. Sleeping on the side or stomach can encourage fluids to collect under the eyes. If patients report being a side sleeper, you may notice a heavier bag on the side they report sleeping on. Patients who wake up with puffy eyes can sleep on their back and add an extra pillow under their head.
I also advise patients to avoid rubbing their eyes, going to bed with makeup on, and using harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

Eye bags could be a sign of an underlying medical condition, especially if bags appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause undereye fluid retention and patients will need to see their primary care doctors for further evaluation.
Patients can place an ice pack, slices of cucumbers, chilled tea bags, refrigerated eye gels, or even a package of frozen peas on their eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

Periorbital hyperpigmentation. Also known as "dark circles."
Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin undereye skin. Patients should avoid rubbing the area. Chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened undereye skin.
Retinoic acid creams can help slough the dark pigmented skin. It should, however, be used in very small amounts that increase over a few weeks to avoid severe irritation.
Skin lightening creams with azaleic acid, kojic acid, and glycolic acid can be found in varying strengths. Hydroquinone creams have been successful in lightening undereye hyperpigmentation. Strengths in over-the-counter preparations start at 1-2% and in prescription strength can be compounded to higher than 4%, but caution should be used to avoid further irritation and potential post-inflammatory pigment from these products.Light chemical peels can assist in lightening dark undereye pigmentation. Peels with hydroquinone or retinoic acid can be used for an added lightening benefit.Intense pulse light can help minimize undereye pigmentation, particularly UV-induced pigmentation. Q-switched lasers have also been reported to be effective.

Infraorbital tear trough depression.
Most often, dark circles aren't about changes in the color of the skin. Instead, they're created by a loss of volume in the area around the eye, exposing the orbital bone and creating a hollow trough that shows up as a dark circle. These changes are often genetic, but significant weigh loss can also expose undereye tear trough depressions.The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Use caution, however; this is a highly technical and injector-dependent procedure.
There are crucial vascular structures around the eye that need to be avoided, and over-filled troughs will give patients a puffy appearance and may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not FDA approved to treat undereye depressions, so patients should be knowledgeable to the risks and benefits prior to undergoing these procedures.

Periorbital vascular prominence.
With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin, which can cast dark shadows and make the area appear dark.Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.For large blue veins, vascular lasers such as a long pulse Nd:YAG laser can be recommended. However, in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques.

Periorbital static and dynamic rhytids.
Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3-4 months apart will ensure long lasting benefits and because botulinum toxin wears off, repeat treatments are needed. Laser resurfacing with CO2 or fractionated CO2 lasers provide excellent benefit for periocular rhytides. A traditional CO2 laser may require repeat treatment in 6-12 months. Fractionated CO2 lasers typically require 4-6 treatments spaced about 4 weeks apart to provide benefit.

Overall tips:
For most of the types of infraorbital issues, makeup can help conceal or mask some imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If they have mild discoloration, I advise that they pick a liquid formula for more prominent imperfections. A cream, full coverage concealer works best. Patients should quit smoking, which dehydrates the skin and causes premature aging and collagen degradation. I always remind patients to apply sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation. I advise patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated


Researchers have developed synthetic platelets that can mimic the actual physical features of natural platelets and their blood-clotting mechanism, according to a study published in the journal Advanced Materials. "The synthetic platelets can have profound implications in wound-healing problems for trauma and wounds arising in both battlefield situations and during surgery," said researcher Frank Doyle of the University of California, Santa Barbara. InnovationNewsDaily.com (5/30


Stem cells derived from fat do show promise in plastic surgery and regenerative medicine, but more research is needed to firmly establish the safety and efficacy of this therapy in humans.

This is the main finding of a review article on adipose stem cells that appears in June issue of Plastic and Reconstructive Surgery.
So far, most studies have been performed in Europe and Korea. Due to stringent FDA regulations, only three adipose stem cell studies have been performed in the US. Less than 300 patients worldwide have been treated. Most clinical trials to date have been performed in plastic surgery.
While results of some studies are promising, there is no standard protocol for the preparation or clinical applications of these cells. "Clinicians and patients alike have high expectations that adipose stem cells may well be the answer to curing many recalcitrant diseases or to reconstruct anatomical defects," study authors conclude. However, even as the number of studies using increases, there is continued concern about their "true clinical potential."
Moreover, “there are questions related to isolation and purification of adipose stem cells, their effect on tumor growth, and the enforcement of FDA regulations."
Plastic surgeon-researchers have used these stem cells for breast augmentation and lipodystrophy. The cells have also been used to promote healing of difficult wounds and as a method of soft tissue engineering or tissue regeneration.
Going forward, "Further basic science experimental studies with standardized protocols and larger randomized controlled trials need to be performed to ensure safety and efficacy of adipose stem cells in accordance with FDA guidelines."
[Source: Plastic and Reconstructive Surgery]


Non steroidal anti-inflammatory drugs (NSAIDs) may help reduce risk of developing squamous cell carcinoma and malignant melanoma, according to a new study published online in Cancer.
Sigrún Alba Jóhannesdóttir, BSc, of Aarhus University Hospital in Denmark, and colleagues analyzed medical records from northern Denmark from 1991 through 2009 and identified 1,974 diagnoses of squamous cell carcinoma, 13,316 diagnoses of basal cell carcinoma, and 3,242 diagnoses of malignant melanoma. They compared information, including NSAID prescription data, from these patients with that of 178,655 individuals without skin cancer.
Those individuals who filled more than two prescriptions for NSAIDs had a 15% decreased risk for developing squamous cell carcinoma, and a 13% decreased risk for developing malignant melanoma than those who filled two or fewer NSAID prescriptions, the study showed. The longer participants took the NSAIDS, the lower their risk for these skin cancers.
Exactly how, or even if, NSAIDS affect skin cancer risk is not fully understood, but these drugs target the cyclooxygenase-2 (Cox-2) enzyme, which is also expressed by certain cancers. “We hope that the potential cancer-protective effect of NSAIDs will inspire more research on skin-cancer prevention,” says Jóhannesdóttir, in a press release. “Also, this potential cancer-protective effect should be taken into account when discussing benefits and harms of NSAID use.”
[Source: Cancer]


Dr. Hector Oscar Molina of Colleyville is, in a way, a by-the-book M.D.
At least, that's how he learned liposuction surgery before performing it, the Texas Medical Board says.
Molina, 47, performed nine hours of in-office liposuction on a patient, who suffered severe complications, according to board records. The board found flaws to this approach.
Molina performed the surgery despite having determined that the patient was unsuitable for it, according to board documents.
More problematic, his "entire knowledge" of the procedure consisted of reading a book written by the liposuction equipment maker, completing a two-week online program, passing an online exam and completing one procedure under the supervision of another surgeon, the board said.
Molina is listed in online board records as a general-practice pain-management/rehab physician. He was not at his Irving office Thursday and could not be reached at home.
In a news release last month, the board said Molina was "barred from performing any cosmetic, plastic or reconstructive procedures."
The board's temporary restriction order took effect April 13 and remains in effect until superseded by another order.
Molina has had past troubles with the board.
In 2004, he was fined $25,000 and his license was restricted for three years after the board found that he had prescribed controlled substances and dangerous drugs over the Internet without seeing patients, performing a physical examination or completing an adequate history.
He was ordered to alter his Drug Enforcement Administration certificate to eliminate authority to prescribe certain controlled substances, board records say.
The action came after a Colorado resident filed a complaint saying he obtained drugs prescribed by Molina from an Internet pharmacy. In court filings with the State Office of Administrative Hearings, Molina was accused of doing so "numerous times."
A patient identified as D.C. in board documents obtained hydrocodone from the website, which Molina was accused of prescribing. D.C.'s wife told the board that her husband was in drug rehab as a result of hydrocodone addiction.
The board ended Molina's probation after a year and eight months.
Records also show that in 2009, he ignored a board subpoena in a legal case and was fined $500. The public records on that order don't specify the nature of the case.
Records indicate that Molina also had a scrape with the law in Tarrant County.
In May 2010, police responded to a report of assault with bodily injury and involving family violence at a $1.3 million Colleyville home identified in board records as Molina's. Court records show that he was fined $246 and put on three months' probation in April 2011 after the matter was disposed as assault by contact.


HT William Edward McElligott jt 120603 wblog Sunny Side Old: Pic Reveals Suns Aging Effects

William (Bill) Edward McElligott is two different ages, 66 and 86 years old.
If you look at McElligott from the right, he looks like any 66-year-old would expect to, but from the left, wrinkles and sagging skin place him far beyond his years. He is a living demonstration of the importance of protecting your skin from the sun.
“It would take me an hour to drive to work and an hour to come home,” McElligott said. “It was a semi route, I’d have six to eight stops. … 6 a.m. to 3 p.m. on the road.”
For almost 30 years, McElligott drove a truck during prime sun hours throughout the city of Chicago delivering milk to stores and gas stations.
“My left arm was always more tan than my right, because a lot of the time I had the window open (since) we didn’t have A.C.,” McElligott said.
The 66-year-old truck driver suffers from unilateral dermatoheliosis or photo-aging, which was caused by repeated, long-term exposure to UVA rays of the sun.
It was 15 years before he noticed any difference between the two sides of his face, but McElligott ignored it, that is until his grandchildren’s questions got the best of him.
“Only reason I went in, the kids were asking me what these bumps are and it’s hard to explain to little kids, so I went to see if I could have those bumps removed,” he said.
Dr. Jennifer Gordon a dermatology resident at UT Southwestern saw McElligott while on a rotation at Northwestern in Chicago and submitted his case study, which was featured in the April edition of the New England Journal of Medicine.
“It was very stark,” Gordon said. “We are used to seeing photo damage, photo aging every day, (but) for it to be so one sided? We were taken aback.”
Gordon explained that since McElligott spent so much time in his car, his left side was exposed to UVA rays that can penetrate glass and cause the majority of photo-aging, unlike UVB rays, which cause sunburns.
“We think its because it (UVA) can penetrate more deeply into the skin than UVB and affect your collagen and elasticity,” she said. “When you destroy those that’s what gives you the aging appearance that we see.”
Dr. Mitchell Chasin, a dermatologist who did not treat McElligott, says it is extremely common to see patients that come in with more damage to their left side than their right.
“Most people are completely unaware and most people who come in to have sun damage treated, they often times will point to their left side saying they see more spots, more wrinkles, more aging, but never put two and two together,” said Chasin, the medical director of Reflections Center for Skin and Body in Livingston, N.J.
Chasin says that whenever people are outdoors, even when covered from the sun directly or on a cloudy day, they should be aware they are not safe from the reflected rays of the sun and should wear sunscreen.
“Sun block is the answer, really, for someone 365 days a year, whether it’s cloudy whether it’s sunny, whether someone is outdoors, in the car, or at the beach,” Chasin said. “If someone wants to age as best they can, sun protection is a daily regimen no matter what you are doing. Put sun block on before you leave the house.”
With summer approaching and vacations and road trips, it’s important to make sure your sunblock has protection against both UVA and UVB rays.
Last year the FDA demanded sunscreen manufacturers update their labels to offer protection for both UVA and UVB, as well as to stop the use of misleading claims such as waterproof. The agency recently extended the deadline to December for manufacturers to comply.
For McElligott sunscreen with UVA and UVB protection has become a daily fixture.
“When I’m out in the sun, when I’m going to be driving, I have sunscreen on,” he said. “I always carry it with me.” He also hopes to get the left side of his face fixed within the next month.
Gordon, although no longer treating McElligott, recommended a resurfacing laser to correct the advanced aging, a technique that can reduce facial wrinkles and scars by removing the damaged skin through a targeted beam of light, according to the American Society of Plastic Surgeons.
And for McElligott to have both sides of his face represent his age would make him “very happy.”
“That way my grandkids will quit asking me, ‘what are these bumps, grandpa?’” he said.


With little recognizable but an eye and chin, the man who lost most of his face in a vicious attack by a raving naked man on a Miami causeway is up against daunting medical challenges, including the possibility of infection delivered through human bites.

For now, Ronald Poppo, who has lived half his life on Miami’s streets, is without his most basic features.
“The loss of the face is one of the most devastating injuries because in so many ways it defines our identity,’’ said plastic surgeon Chad Perlyn, an assistant professor in the surgery department at Florida International University’s Herbert Wertheim College of Medicine. “He has a long road back, both physically and psychologically.’’
In a random encounter, Poppo, 65, was assaulted on the busy MacArthur Causeway over the Memorial Day weekend. As cars zoomed by, his attacker, Rudy Eugene, chewed off chunks of Poppo’s face in what police suspect was a drug-fueled rage. Detailed online photos of what is purported to be Poppo’s face show the left eye gouged out and the other features — eyelids, nose and lips — gone. Police have reported Poppo to be in critical condition. The Ryder Trauma Center at Jackson Memorial Hospital will not confirm his condition or release any personal information until they receive consent from a family member or surrogate.
But a police union representative for the officer who stopped the attack described the devastation to Poppo’s face. “He had his face eaten down to his goatee. The forehead was just bone,” Sgt. Armando Aguilar, president of the Miami Fraternal Order of Police, told the Associated Press. “No nose, no mouth.”
Poppo’s recovery will take months, possibly years, of medical and psychological treatment in a costly and ambitious effort to rebuild the features on his face or, possibly, replace it altogether in a transplant that has only been performed about two dozen times in the world. One of the most recent procedures, performed in March, was led by a Miami-born doctor, Eduardo Rodriguez.
“The human mouth has one of the highest counts of bacteria, and with bites where the skin is punctured, the teeth and saliva carry the bacteria into the wound,’’ said Perlyn, part of the Miami Children’s Hospital plastic surgery team. “The key to his injuries beyond the infections is determining how much tissue damage or loss there is. Damaged tissue can be repaired, but where there is loss, the feature must be reconstructed.”
Though few details are available about Poppo’s condition, several plastic surgeons and experts — none treating the patient but experienced in facial reconstruction — say that doctors treating a patient with such extensive injuries would confront steep challenges to construct a semblance of a normal face.
“Based on the extent of his injuries, he has a really tough road ahead. Facial reconstruction is difficult in the most simplistic case of trying to restore a feature back to the exact form and function,” says Dr. Reza Jarrahy, the co-surgical director of the University of California at Los Angeles Health Systems’ newly launched Face Transplantation program.
First, a team of Jackson doctors is focused on keeping Poppo stable, making sure his wounds are clean, hydrated and covered. They will work to build up his immune system to ward off infections through antibiotics and proper nutrition. They must take into account that Poppo has been homeless for more than 30 years, survived a gunshot and had been a chronic drinker.
They must also work to preserve his airways and the remaining eye, if possible. The eye is particularly vulnerable because the eyelid, which serves as a protector, was reportedly destroyed.
“The patient will probably have to have several trips to have the wounds washed out so that doctors can assess the viability of the tissue. They have to temporarily cover the exposed eye and cover any other open wounds, with a dressing,’’ said Rodriguez, chief of Plastic Surgery at R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center in Baltimore. “Then they have to start making decisions about the best way to reconstruct the patient’s face.’’
In March, Rodriguez led a team of 100 specialists and support personnel in the longest and most extensive face transplant to date. For 36 hours, Rodriguez and his team worked to replace a face, from hairline to neck, for Richard Lee Norris, 37, who had been shot in the face. Terribly disfigured, Norris had had been wearing a mask and living as a recluse for 15 years.
A face transplant can cost about $350,000 or more, depending on the complexity of the procedure, along with the cost of a lifelong regimen of immunosuppressive medication. For reconstructions, the cost can be comparable. Late last week, the Jackson Memorial Foundation established a fund for Poppo’s care and already people from across the nation have asked about donating.
While the cost to help Poppo may be high, at least one medical ethicist says medical need comes first.
“University of Miami and Jackson pride themselves on the fact that poor people get really good care. A wallet biopsy is not done before the person is treated,’’ said Kenneth Goodman, director of the Bioethics Program at the UM Miller School of Medicine, which provides physicians for Jackson. “If there is good clinical indication that the patient needs the procedures, then I think reasonable people would say let’s try to find a way.”
For Poppo, options could include taking skin and bone grafts to rebuild his features. Typically, the forehead can be used as a source of skin to help in reconstruction. If that is not possible, doctors can turn to another nearby region, such as the neck. Part of a broader reconstruction plan, the procedures would likely take place in phases and over a long period of time, said Dr. Seth R. Thaller, of the University of Miami.
“You have to take a global approach. You have to have an interdisciplinary team, which Jackson has, that can work prioritize and make appraisals along the way,’’ said Thaller, chief of the plastic surgery division at the UM Miller School of Medicine. “Ultimately, with a devastating injury, the goal is to get the patient to a point where they can function, where they can walk into a room with an acceptable appearance. It may not be what they looked like before, but at least it’s presentable.’’
In discussing Poppo’s case, experts cite a Connecticut woman’s injuries from a brutal attack by a 200-pound chimpanzee as a reasonable comparison to what may lie ahead for the Miami man.
Charla Nash was viciously mauled in 2009 by a friend’s pet, losing her nose, an eyelid, lips and both hands. Because of infection, doctors removed her eyes. Last year, she received a donated new face after 20 hours of surgery at Brigham and Women’s Hospital in Boston. She also received new hands, but after she contracted pneumonia they had to be removed.
“She had her face and hands ripped off,’’ said Nash family spokesman Ara E. Chekmayan. “There is the trauma of the actual attack, and then there is the trauma of her understanding what happened to her. She was fortunate in that she had a family and support system which is an important component of recovery.’’
Three years after the attack, Nash can speak and eat. She is in physical rehabilitation and will be on medication for the rest of her life.“Her life was turned upside down,’’ he said.
“She lost what we take for granted: that you look in the mirror and see something familiar. She is a very positive person, but everyday is a struggle. She still has good days and bad days.’’


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