Paraphrased from Plastic and Reconstructive Surgery Journal. June 2017.

Postmastectomy Irradiation and the case for immediate or delayed Autogenous Tissue Breast Reconstruction

Colwell, Amy S. M.D.
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1289–1290

The evolution of mastectomy has advanced from radical to modified radical and now skin- and nipple-preserving mastectomy procedures without oncologic detriment to the patients.

In a similar way, radiotherapy has undergone significant changes from rudimentary two-dimensional planning with cobalt to more targeted three-dimensional planning with intensity-modulated radiation therapy, volumetric-modulated arc therapy, and proton therapy with pencil beam scanning.

This specificity has allowed improved targeted therapy and reduced the bystander effect on surrounding normal tissue, and this has been essential to the paradigm shift of radiation therapy as a salvage modality to radiation therapy as an integral part of modern breast cancer treatment.

Autologous reconstruction is an ideal option for many patients following mastectomy, particularly in the setting of radiotherapy.

Immediate autologous reconstruction has several advantages, including the psychological benefit of awakening from mastectomy surgery with a breast mound, and the practical benefits of fewer operations and decreased operative time if the reconstruction is begun simultaneously with the mastectomy.

However, experience gained from large series in the past showed high incidences of fat and flap necrosis, volume loss, and complications when immediate autologous reconstruction was performed before radiation therapy.

Therefore, delayed autologous reconstruction has been the most common choice in patients destined to undergo postmastectomy radiotherapy.

However, with improvements in surgery and radiation techniques combined, several authors have begun to reexplore immediate autologous reconstruction in this setting.

The Mastectomy Reconstruction Outcomes Consortium Study offered a potential way to answer the question of whether immediate autologous reconstruction should be performed in women who require postmastectomy radiation therapy.

In this article, immediate reconstruction was performed in 108 patients. This cohort was unique in having no total or partial flap losses and a very low (3.7 percent) rate of fat necrosis, which is a testament to the technical skills of the surgeons involved.

Information regarding the delivery of radiotherapy specifics was not collected at all sites, but the regimen at this center used slightly smaller fractions of radiation for delivery compared to other sites where doses were known, there were no radiation boosts, and selected nodal treatment was performed.

In comparison, the delayed cohort (67 patients) offered a true multicenter experience and reported rates of partial flap necrosis (7.5 percent) and fat necrosis (10.5 percent) comparable to those in the literature.

Overall, there was no difference in total breast complications between immediate and delayed reconstruction.

Furthermore, patient-reported satisfaction scores between immediate and delayed cohorts were similar at 1 and 2 years.

The results from this study show that as surgery and radiation therapy continue to evolve, immediate breast reconstruction should definitely be considered.

However, the question of whether immediate breast reconstruction should be performed can only be answered at each institute based on surgical expertise and radiotherapy delivery unique to each health care system.

REFERENCES

1. Clarke M, Collins R, Darby S, et al. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of
radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year
survival: An overview of the randomised trials. Lancet 2005;366:2087–2106.
Cited Here... |
PubMed | CrossRef

2. Katz A, Strom EA, Buchholz TA, et al. Locoregional recurrence patterns after mastectomy and doxorubicin-based
chemotherapy: Implications for postoperative irradiation. J Clin Oncol. 2000;18:2817–2827.
Cited Here... |
View Full Text | PubMed | CrossRef

3. Kronowitz SJ, Robb GL. Radiation therapy and breast reconstruction: A critical review of the literature. Plast
Reconstr Surg. 2009;124:395–408.

Paraphrased from Plastic and Reconstructive Surgery, Jun 2017:

The case for Autologous Breast Reconstruction rather than Implant Reconstruction in Irradiated Patients.

Methods: From the 2009 to 20130, irradiated breast cancer patients who underwent implant or autologous reconstruction were selected.

Results: There were 2964 study patients. Most (78 percent) underwent implant reconstruction. The unadjusted mean costs for implant and autologous reconstructions were $22,868 and $30,527, respectively.

Thirty-two percent of implant reconstructions failed, compared with 5 percent of autologous cases.

Twelve percent of the implant reconstructions had two or more failures and required subsequent autologous reconstruction.

The cost of implant reconstruction failure requiring a flap was $47,214, and the cost for autologous failures was $48,344.

In aggregate, failures constituted more than 20 percent of the cumulative costs of implant reconstruction compared with less than 5 percent for
autologous reconstruction.

Conclusions: More than one in 10 patients who had implant reconstruction in the setting of radiation therapy to the breast eventually required a flap for failure.

These findings make a case for autologous reconstruction being primarily considered in irradiated patients who have this option available.

Reference:
Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast: A National Claims-Based Assessment

Aliu, Oluseyi M.D., M.S.; Zhong, Lin M.D., M.P.H.; Chetta, Matthew D. M.D.; Sears, Erika D. M.D., M.S.; Ballard, Tiffany M.D.; Waljee, Jennifer
F. M.D., M.S.; Chung, Kevin C. M.D., M.S.; Momoh, Adeyiza O. M.D.

Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1224e–1231e

My experience with Dr. Michelow as a 4th year Medical Student

The following story occurred during my third year of medical school.

The man we were called to consult was 43 years old.  He was homeless, and due to prolonged lack of medical care a wound on his foot had developed into necrotizing fasciitis.  This occurs when an opening in the skin becomes infected with a destructive bacteria that subsequently ‘eats’ down to the fascia and muscle, and if left untreated can be deadly.  The surgeon I was following quickly evaluated the man and, with little explanation, told him that his leg would need to be amputated.  The man refused, and after we removed as much infected tissue as we could, was sent to the hospital’s inpatient ward with strong antibiotics.  The following day, we again consulted the man, and the surgeon again told him that the only option was amputation, with the only explanation being impending death.  The man again refused surgical removal of his leg.  I spent the next few weeks of my general surgery rotation checking in on him.  Four weeks later, the man left the hospital.  With his leg.

This is exactly the opposite type of care I have witnessed Dr. Michelow provide his patients.   I am now in my fourth year of medical school, and I have witnessed hundreds of interactions between doctors and patients.  I know a great doctor when I see one, and I believe Dr. Michelow is a great doctor, but allow me to explain what I mean by greatness.

Greatness can be achieved in any aspect of life, but I believe that greatness in the realm of medicine has two aspects; skill and humanity.  Skill is acquired through practice and training, which I will not delve into here as Dr. Michelow’s experience and training speak for themselves and can be found on his website.  Humanity, on the other hand, is something that I believe most physicians start their training with, but not all succeed in holding onto it.  I believe the surgeon’s pitfall in the above story, failure to recognize the patient as a fellow human being, was a loss of humanity.  However, Dr. Michelow has indeed held on to his, and will be a model for which I can refer to throughout my training.  Let me provide you an example.

A woman in her late 50’s came into the office requesting botox and fillers for fine lines and other imperfections she thought she saw in herself.  After a thorough discussion, Dr. Michelow softly recommended something I never expected to hear from a cosmetic surgeon; do nothing.  The patient I could tell was thrown off guard, and echoed my own thoughts by saying “I’ve never had a cosmetic surgeon tell me I didn’t a treatment.”  It was shining moment for medicine in my opinion, as the patient left seemingly happy and more confident in herself, and did so without any cosmetic treatment.

I will not be pursuing a career as a cosmetic surgeon, as my calling has been for pediatrics.  But what I’ve learned is that compassion and humanity can be found in all corners of medicine, not the least of which include Dr. Michelow’s office at Contemporary Cosmetic Surgery.

Nathan McGraw OMS-IV
2LT, US Army

Scar Care 101

Understanding Scars
When a person sustains a minor injury, such as a scrape after a fall, a scab typically forms.  When the scab falls off, the skin may be pink or reddish in color, but over time this will fade and the skin will return to normal.  Wounds such as these only cause a partial thickness skin injury and are likely to heal without significant scarring because there is sufficient remaining skin to regenerate the surface layers.

Conversely, when a full thickness injury through the skin occurs from an accident or following surgery, the skin does not regenerate, but rather it heals with scar tissue.  Scar tissue consists of collagen, whereas skin consists of the dermis and epidermal cells.  Although scar tissue is similar to skin, it is not identical and that is why a scar can always be differentiated from regular skin.

Scars are permanent!

Skin is elastic. When lacerated, the edges of the wound pull apart. When an open wound is closed with stitches, the skin along each side of the wound is pulled together with stitches.  The skin, being elastic, tries to return to its original position. Because the healing scar tissue is only 80% as strong as natural skin, the scar will stretch and may result in a wide scar.  

In an attempt to prevent the scar pulling apart, the healing scar may thicken and bulge above the level of the surrounding skin.

Scars typically thicken for the first few months after injury occurs and then will soften and flatten over a period of a year or two.  The red color of the scar will also fade over a period of a year or two. A mature scar will usually be lighter than the surrounding skin.

The surgeon has a partial role to play in the healing of the scar. The surgeon is able to control the neatness of his or her stitching of the scar and the tension in the closure of the wound. After the wound has been stitched, the healing that occurs thereafter depends on many factors.   Some of these factors include the following:

 Patient Factors
o The patient’s genetic makeup
o Overall health
o Diet
o Smoking
o Diabetes
o Tension of the scar
o Stretching/pulling of the wound (may contribute to a wide or thick scar)

 Complications
o Separation of the wound edges
o Development of wound infection

Scar Treatments
In general, there numerous options to improve the appearance of scars:

1) Over-the-counter or prescription creams, gels, oils, ointments, and tapes
2) Dermatological interventions such as chemical peels, microdermabrasion, dermaplaning,
        lasers, fat grafting.
3) Surgical revision.
4) Steroid or collagen injections – These injections help soften scars and may shrink them.
5) Indented scars may respond to dermal filler injections.
 

Scar Care Products 

While the wound is open, follow the treatment recommendation of your health care provider.

There are many products available on the market to improve the appearance of scars.  Wait until the wound is completely closed before beginning scar treatments.

Silicone-Based Products:
Silicone based products have been shown to improve the appearance of scars.  A study by Puri and Talwar (2009) found

that silicone produces an 86% reduction in scar texture, 84% in color improvement, and 68% reduction in scar height.  These products are available as gels and tapes.

Some advantages of using a silicone based product are the following:

      Increased skin hydration thereby facilitating the regulation of fibroblast production
         rather than collagen production. This results in a softer, flatter scar.
      Reduces itching and discomfort associated with scars.

Silicone Gels – A thin layer of a silicone based gel will dry within 4-5 minutes of application and work for 24 hours.

Silicone Based Tapes - These products come packaged as squares that can be cut into appropriate sizes to cover the scar.

Generally, patients should wear the scar strips over the scars for a number of weeks for optimal results.

Mederma:
Mederma products claim to improve the overall appearance, color, and texture of scars.  The active ingredient in this products is the common onion, or allium cepa.

Onion extract apparently reduces inflammation, inhibits bacterial growth, and regulates excessive collagen growth.  While these properties seem as though they would be effective, clinical research shows mixed results on scar products using the onion as the active ingredient.  

Bio Oil:
Bio Oil is a moisturizing oil that claims to improve the appearance of scars, stretch marks, uneven skin tones, aging, and dehydrated skin.  Bio Oil contains plant extracts and vitamins which are mixed into an oil base.  It contains both Vitamin A and E, but the breakthrough ingredient, PurCellin Oil, is what Bio Oil claims makes the formula light and non-greasy, allowing for better absorption of the vitamins and plant extracts.

Vitamin E:
Many believe that putting vitamin E on scars will improve their appearance; however, there is a paucity of scientific evidence that supports this notion.  Vitamin E does influence the formation and arrangement of collagen fibers.

Dos and Don’ts of Scar Care
To lower the chances of developing a more noticeable scar, we recommend the following scar tips:

• Protect the scar from the sun for several months to avoid permanent darkening of the scar.
• Do not apply any scar care products until the wound is completely closed. 
• Gently massage the scar twice daily to assist your body in the remodeling process.

Vanessa Lelli, CNP
Bryan J Michelow, MD

Tanning: How to Avoid the Dangers of Skin Cancer

While a bronzed glow is desired by many, the process to achieve this look can be deadly!

Whether you are catching rays outdoors or in a tanning booth, the ultraviolet (UV) rays are hard at work causing irreversible skin damage and premature aging.

Many believe that if they tan indoors for a shorter amount of time, they are limiting their risk; however, this is not the case.  People who regularly tan indoors are actually 74% more likely to develop melanoma, the deadliest of skin cancers, when compared to those that tan outdoors only (Skin Cancer Foundation, 2015).

Tanning and Skin Cancer
Did you know that in today’s world, the risk of developing skin cancer from tanning is higher than a person developing lung cancer from smoking?

The three most common types of skin cancer are Basal Cell Carcinoma, Squamous Cell Carcinoma, and Melanoma.

The risk for developing skin cancer increases significantly with UV exposure (Skin Cancer Foundation, 2015).

Melanoma, the deadliest of skin cancers, is on the rise in young adults and has become the most common form of cancer for those 25-29 years old. In addition, it is the second most common cancer for young people 15-29 years old.  On average, a person’s risk of developing a melanoma doubles if he or she has had more than five blistering sunburns (Skin Cancer Foundation, 2015).

How Do Sunless Tanners Work?
The safest way to achieve a tanned look is to use sunless tanning products.  

Sunless tanning products contain an ingredient called dihydroxyacetone (DHA) which is also known as glycerone.  Glycerone is a simple sugar, a triose, with the formula: C3H6O3. When the sugar interacts with the proteins (amino acids) that are naturally located in the outermost layer of your skin, the epidermis, it causes a chemical reaction that produces a tanned color ranging from yellow to brown.

Sunless tanning products contain DHA in concentrations ranging from 1% to 15%. Most products found in your local pharmacy range from 3% to 5%, with professional products ranging from 5% to 15%. The higher the concentration of DHA, the darker the skin color.

Lighter products are easier to obtain a more even tan but may require multiple coats to reach the desired depth of color.

Darker products produce a dark tan in a single application, but streaking may be a consequence.
The artificial tan takes 2 to 4 hours to begin appearing on the skin surface and will continue to darken for 24 to 72 hours, depending on formulation type.

Once the darkening effect has occurred, the tan will not sweat off or wash away with soap or water.

Since skin cells undergo rapid turnover and naturally slough off every 3-7 days, thus the tan will fade and will need to be repeated.  Exfoliation, prolonged water submersion, or heavy sweating can lighten the tan, as these all contribute to exfoliation of the surface skin cells that have been tinted by the sunless tanner.

Research has demonstrated that for 24 hours after sunless tanner application, the skin is especially susceptible to free-radical damage from sunlight. Therefore, it is recommended that for a day after self-tanner application, excessive sun exposure should be avoided and a sunscreen should be worn when outdoors.

An antioxidant cream may also minimize free radical production. Although some self-tanners contain sunscreen, the effect does not last long. Despite darkening of the skin, an individual is just as susceptible to harmful UV rays. A sunless tan, therefore, will not protect the skin from UV exposure.

A word of caution from a toxicologist and lung specialist at the University of Pennsylvania's Perelman School of Medicine: Inhalation of the fumes of the sunless tanners may enter the lungs and be absorbed into the body. The compounds may promote the development of cancers.

When used topically, sunless tanners have been approved by the FDA as safe.

Types of Sunless Tanners
There are many different types of sunless tanning products on the market. These products range from sprays, mousses, gels, lotions, creams, and cosmetic wipes that are available at your local drug store.

Professionally applied products include spray tanning booths and airbrush tan applications.

Common Tanning Myths 

• Tanning indoors before you go on a big vacation is good so you can get a base tan.  MYTH!

The body’s response to UV injury is a tan.  Regardless of whether you tan before or on your vacation, you are injuring your skin!  You are still at high risk of burning regardless of how tanned you are prior to your vacation.

• Tanning in a tanning bed is safer than tanning outdoors. MYTH!

Tanning beds are designed to give you significant levels of UV radiation in a much shorter time.  Tanning for 20 minutes in an indoor tanning bed is equivalent to tanning outdoors for several hours.  One indoor tanning session increases one’s risk for developing skin cancer by 20% and each additional indoor tanning session within the same year will increase your chance by an additional 2% each time (Skin Cancer Foundation, 2015).

• Tanning is a great way to get your Vitamin D. MYTH!

While getting an adequate amount of Vitamin D is important to our overall general health, there are better ways to get it than tanning! The risks of tanning, to boost vitamin D, certainly do not outweigh the benefits.

Fortunately, we don’t live in Iceland and so we usually get adequate amounts of sunshine and Vitamin D from being outdoors. The safest way to ensure adequate levels of Vitamin D is through our diet.  Foods high in vitamin D are mushrooms, mackerel, sockeye salmon, herring, sardines, catfish, tuna, cod liver oil and eggs.

A daily multivitamin with vitamin D is also recommended.    

• Can I still have a tanned torso?

The take home message is sun tanning is very dangerous.  The short term benefits of tanned skin are not worth the serious health risks that could result.  So, yes, you can be tan today, if you change your way.  Don’t delay, just change to a spray!


Vanessa Lelli, DNP, FNP-C
Bryan Michelow, MD

Kybella® - New option to eliminate a double chin without surgery

Prior to the recent approval of Kybella® by the FDA, eliminating a double chin meant liposuction and invasive surgery.  Not any more!

Kythera Biopharmaceuticals received FDA approval in April 2015, for its new product, Kybella®. This is a deoxycholic acid which is a “bile acid”. When injected into the fat below the chin, it helps destroy fat cells.

When the manufacturer was contacted so that an order could be placed for this new product, the representative stated that the “super quick” approval of Kybella® by the FDA was unexpected and injector training prior to distribution is currently in progress.

Kybella® is a bit more complex than neurotoxins or dermal fillers.  It requires a series of injections, for optimal results.

Kybella® will address the double chin fat but not skin or muscle laxity. It is not FDA approved for use elsewhere on the face or body.

How does Kybella® compare to liposuction or surgery?

Kybella® can be injected into the fat under the chin in the doctor’s office. There is unlikely to be any “down time”.  Its effect may last for a few years.

Liposuction offers a more customized treatment and is more predictable in contouring the fat. It also offers gratifying results when swelling from surgery subsides.

Surgical procedures have the advantage of removing the fat of the double chin, tightening the neck muscles and tightening any loose neck skin. The trade off of surgery is the need for an anesthetic and a few weeks for recovery.

Kybella® may “do” for double chins, what Botox® did for facial lines.

This is an exciting option for those patients who are concerned about having surgery and for surgeons who are excited to offer an additional less invasive procedure for unwanted fat under the chin.

Bryan J. Michelow, MD
Office: 216-595-6800

SPF Sunscreen: Is Higher Better?

SPF, or Sun Protection Factor, is a numeric value displayed on sunscreen labels to indicate their ability to block out harmful sun rays.

A common misconception about SPFs is that the higher the SPF, the better the protection.
While there is some truth to this, it is not quite as simple.

As the SPF increases, so does the protection from harmful sun rays, however, once you reach SPF 50 or higher there is only a slight increase in protection.

For example, an SPF of 15 will block approximately 94% of sun rays.  An SPF of 30 will offer you additional protection of about 97%.  Once you reach SPF 50, you will get about a 98% blockage from harmful sun rays, which is only a minimal increase from SPF 30 with 97%.

Thus, increases in SPF are not directly proportional and will only result in a minimal amount of additional protection as the number increases.

Excessive sun exposure increases one’s risk of premature skin aging as well as skin cancer.

We recommend the following to decrease the above mentioned risks:
• Daily use of a broad spectrum sunscreen with an SPF of at least 30.
• If you are spending more than 2 hours outside, be sure to reapply your sunscreen.
        Repeat every 2 hours at least.
• Avoid spending too much time in the sun during the peak hours of sun intensity (10am-2pm).
• When outdoors, protect exposed skin with clothing and a hat

When choosing a sun protection product, there are many options such as sprays, lotions, gels, sunblock, sunscreen, and more!

While the majority of products will work well, consider the following when making your selection:
1) Sunblock versus Sunscreen: 
                  Both will protect you from the sun, but their mechanisms of action differ.
                  Sunscreens contain chemicals such as Oxybenzone and Avobenzone that filter some of the sun’s UV rays to protect your skin.
                 These chemicals breakdown when exposed to UV light and need to be reapplied every 2 hours at a minimum.

                  Sunblock, on the other hand, acts as a physical barrier by reflecting the sun’s rays, thus, blocking harmful sun rays.
                  Most sunblocks will contain either zinc oxide or titanium dioxide.
                  Sunblocks are not broken down by UV light and will last longer provided they are still covering the skin.

2) Sensitive Skin: If you have sensitive skin, we advise you to select a sunscreen that is fragrance free, oil free, and hypoallergenic.

3) Acne: If you have acne prone skin, we recommend selecting a non-comedogenic (won’t clog pores), fragrance free, and oil free sunscreen.

4) Asthmatic:  If you or your child has a history of asthma, we advise caution if using a spray as these could provoke an asthma attack!

Desperately desire a tanned look?  See our next blog on sunless tanners!

Vanessa Lelli DNP, FNP-C 
Bryan J. Michelow, MD, FACS

Cosmetic or Reconstructive Surgery - What is the difference?

Distinctions between Cosmetic surgical procedures and Reconstructive surgical procedures may appear clear, but occasionally these distinctions may be less obvious.

Cosmetic surgery is performed on normal tissue to improve the patient’s beauty. This optional enhancement is not considered medically necessary from a health perspective, but rather a way to alter a person’s appearance to boost their self-esteem.

Examples include body contouring with liposuction, breast augmentation, face lift, and minimally invasive injections of Botox® (one of the many muscle relaxants). Cosmetic procedures are usually not covered by insurance.

Reconstructive surgery is performed to repair wounds, remove a cancer or return function to an injured body part. Some examples include treatment of accidents victims, burn treatment, hand surgery and cleft lip/cleft pallet reconstruction. These procedures are usually covered by insurance policies.

Some procedures fall into a gray area. Breast reduction, for example - if the large size of a patient’s breasts prevents her from performing her activities of daily living, then reduction surgery would be considered reconstructive rather than cosmetic.

An upper eyelid blepharoplasty (excess eyelid skin removal) would typically be a cosmetic procedure. If the patient’s visual fields were compromised, then surgery is required to improve vision. The procedure, therefore, is medically necessary for functional purposes.

When the distinctions between Cosmetic and Reconstructive surgical procedures are less clear, the need to correct a functional impairment implies that the procedure is reconstructive. If the procedure elected by the patient is for the improvement of “looks”, this is indicative of a cosmetic procedure.

Matthew Greenwald.
The Ohio State University.

Snail Slime for your Skin ... Super Food or Snake Oil ?

Lately the media is all abuzz with miracle products promising to naturally tighten, hydrate and rejuvenate your skin.

First it was the bee venom facial pre-Princess Kates wedding and now its snail slime.

Snail slime can be found in skincare products from masks to lotions compounded for dry, normal and oily skin types.

Snail slime sales people tout the slime as being antioxidant rich and packed with hyaluronic acid - an ingredient found in dermal fillers that plump up the skin.

If this is the case should you start collecting snails for their slime?  Is snail slop really a super food, or 21st century snake oil?

As a plastic surgeon I look at the science behind the claims before advising my clients to invest in products and services.
 
A review of the scientific literature revealed a paucity of information about the actual ingredients in the slime produced by snails.  Therefore, the beneficial effect of the slime itself cannot be plugged.

It is more likely that the ingredients that cosmetic companies add into the product provide more benefit than the snail slime.  These add-ins include: Allantoin, a product that sooths irritated skin; Collagen and elastin, that are structural proteins of the skin; Hyaluronic acid, that moisturizes, lubricates and softens the skin. All these ingredients have large molecules that do not penetrate the skin’s protective barrier (stratum corneum).  Therefore, their effect is superficial.

Glycolic acid, another of the added products, is a chemical peel that exfoliates and eliminates dead cells on the skin surface.

In summary, we are unable to find any well-controlled scientific studies that support the beneficial effect of snail slime on rejuvenating facial skin.

As the snow melts and spring blossoms, hold off rushing into the garden to collect the unsuspecting snails!

They, the snails, benefit more from their slime than we humans do!   

Julie Spehar, PA Student

University of Mount Union

Bryan J. Michelow, MD

===###===

What type of filler is right for me?

Although we cannot actually turn back time, we can enhance our natural youthfulness!

How do you see yourself when you look in the mirror? 

Do you see signs of aging?

A common concern for cosmetic patients is facial aging. As we age, our skin loses elasticity which causes it to sag and wrinkle. The sun and gravity are our greatest friends and also foes.

Fortunately, there are many options to correct facial aging, including muscle relaxants, injectable fillers, and more invasive procedures such as surgery. Many patients opt for minimally invasive procedures that include fillers to improve the appearance of their face.

Fillers vary by consistency: Gels, Putties and Powders.

Gels: 
Examples of gels are: Juvederm Ultra®, Juvederm Ultra Plus®, Voluma®, Restylane®, Perlane®, Restylane Silk®, Belotero®

Gels are thin and soft. In addition, they absorb water to plump the appearance of the skin. They can be injected into the cheeks, nasolabial folds, marionette lines, lips, and fine lines around the lips.
Gels create a subtle yet noticeable appearance to the face. This is an ideal first treatment for patients interested in trying fillers. These can last between 4 and 9 months, depending on the specific filler used.

NEW!  Restylane Silk® is an exciting new product, FDA approved, for use in and around the lips. It effectively decreases the "fine lines" and wrinkles around the lips.

Putties: 
Example of a putty filler is Radiesse®

Putties are thicker than gel fillers, which makes them ideal for improving the prominence of the cheek bones. The change that putties provide can be quite striking. This is typically a good treatment for patients who are looking for a significant change. These fillers can last up to one year.

Powders: 
Examples of a powder filler is Sculptra®
Powders are different from putties and gels. The powder is mixed with sterile water for injection. After injecting the water containing the powder into tissue, the skin looks much fuller. Over the next few days, the body absorbs the water and the fullness disappears. The powder remains in the skin and stimulates the tissue to produce collagen over the coming

months. This is the most subtle but the longest lasting treatment, lasting up to 2 years with booster treatments.

The three types of fillers can be used alone, in combination with each other, or with muscle relaxants (Botox®, Dysport®or Xeomin®) in the upper face to enhance youthfulness.

If you have any questions about “What type of filler is right for me?” please Bryan J. Michelow, MD, at Contemporary Cosmetic Surgery, 216.595.6800.

Caitlin Kyle, PA-S
Baldwin Wallace University

Bryan J. Michelow, MD

My Physician Assistant (PA) Elective experience with Dr. Bryan Michelow

The past six weeks spent with Dr. Michelow and his staff has been an absolute blessing.

I had the pleasure of meeting and assisting Dr. Michelow on my General Surgery rotation earlier in the year and had such a pleasant experience that I was elated to have the opportunity to do my elective with him in Plastic Surgery. Not only is he a fabulous surgeon and teacher, but he is a wonderful person.  He takes an interest in each and every person he comes in contact with and is never too busy to lend a helping hand.

I have learned so much throughout this elective rotation.  I was encouraged to think abstractly and apply my knowledge and skills while in the office and in the operating room.  I was given the chance to assist on the majority of the cases that were encountered during my time here including: skin grafting, skin cancer excisions, panniculectomy, blepharoplasty, breast augmentation, mastopexy, incision and drainage, breast reduction, and various hand surgeries.

In addition to assisting in surgery and seeing patients in the office, Dr. Michelow took me to a conference on Pediatric Emergency Medicine, and arranged for me to take a private suturing class.  I was also able to attend his monthly hand clinic and gain insight into the management of debilitating hand injuries.

I am so thankful to have had this opportunity and to have met such wonderful people.  The information and skills that I have learned here are invaluable.  I have no doubt that my experiences here have given me perspective and have solidified my interest in the extraordinary and challenging world of surgery.

Thank you Dr. Michelow, Cheryl, Roxanne, Andrea, and Jill for such a welcoming and rewarding experience!

Alexandra Messmer
Physician Assistant Student – University of Findlay

Calciphylaxis - an unusual but interesting condition

During my elective rotation at Dr. Michelow’s office, I was able to see a large amount of patients with a vast array of conditions.

One particular case that sparked my attention was a woman with presumed calciphylaxis of the lower abdomen. I was so intrigued by this condition that I decided to do my end of rotation presentation on calciphylaxis. 

Here is what I found:

Calciphylaxis is a condition where calcium is deposited in the subcutaneous and cutaneous tissue, as well as in the vessel walls. The continued calcification leads to vascular occlusion which impedes blood flow and ultimately leads to necrosis of the tissue. 

The exact etiology of calciphylaxis is unknown, however there are many risk factors that predispose a patient to this condition. The most noteable risk factor is chronic kidney disease, especially those patients requiring dialysis. The kidney does not properly excrete calcium and phosphate and often the dialysate utilized is high in phosphate and/or calcium. The calcium and phosphate then bind and precipitate, thus causing vascular occlusion. 

Another risk factor includes uncontrolled Warfarin levels. Warfarin inhibits a vitamin-K dependent factor that is responsible for inhibiting vascular calcification. 

Additional risk factors for calciphylaxis include alcoholic liver disease, diabetes mellitus, connective tissue disorders, glucocorticoid use, chronic inflammatory conditions, and clotting disorders.

Calciphylaxis typically presents as a tender, erythematous areas of skin. The lower extremities are most commonly affected (90%). Other areas that may be involved include the abdomen and the buttocks. These lesions progress to reddish-purple plaques and ultimately end up as a black stellate eschar overlying gangrenous ulcers and patches of ischemic necrosis.

Diagnosis is typically made by deep tissue biopsy. Incisional biopsy of the skin could result in a non-healing ulcer which increases risk of mortality 2-fold. Additional diagnostic tests that may help include plain films showing calcium deposits in the vessels.

The goal of treatment of calciphylaxis  is to lower calcium and phosphate in the blood. This is accomplished by Cinacalcet, which makes receptors more sensitive to calcium, and Sodium Thiosulfate which increases the solubility of calcium deposits. A non-calcium phosphate binder such as Sevelamer will decrease phosphate levels. Wound management should be optimized and prophylactic antibiotics may be necessary to prevent secondary infection. Surgery may be considered to excise the areas of vascular compromise if the patient is fit for surgery.

Unfortunately, the mortality rate for calciphylaxis is 85%. The 1-year survival rate is 45% while the 5-year survival rate is only 35%. The most common reason for mortality is sepsis. Factors that increase mortality rate include proximal lesions and ulceration.

The plan for the patient that I saw was to undergo a deep tissue biopsy to confirm the diagnosis. Once confirmed, she will be started on Cinacalcet or Sodium Thiosulfate. Wound management will be optimized with a multi-disciplinary approach and strict adherence to the medical regimen. Her prognosis is guarded.

Julie Shawver PA-S

Mount Union Physician Assistant Program

Beautiful, Natural, Noticeable

Breast Augmentation so naturally attractive you will forget that you have implants.

Dr. Michelow's "Hidden Incision" combined with the new tear-drop shaped, high-strength, cohesive silicone gel implants add volume and fullness where these should be...for natural breast enhancement.
Tighten, lift and achieve the silhouette you want and an appearance that will turn heads

www.DrMichelow.com


3733 Park East Drive Suite 107
Beachwood, OH 44122
216 595 6800

Best Results Obtained When Your Surgeon is Certified by the American Board of Plastic Surgery

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Scary Scars - Simple Solutions!

Jennifer Kish, DO, FACEP  Seriously Skin 

Bryan J. Michelow, MD  Contemporary Cosmetic Surgery

Dr. Jennifer Kish (Seriously Skin) and Dr. Bryan Michelow (Contemporary Cosmetic Surgery) have teamed up to treat those tough, thick scars that can be unsightly.

What are scars?
Healthy skin consists of two layers (Epidermis and Dermis). However, after an injury to the skin, be it a cut, a burn or an operation, the skin will heal with a scar. Scar tissue consists of collagen fibers.
Because of this difference, scars are visible.

Why do I get scars?
If the injury to the skin is superficial, like an abrasion or a "road rash" following a fall, the skin will heal from the uninjured deeper dermal cells.  A scab may initially form. As the wound heals, the scab falls off leaving healthy skin.

If, however, the wound in the skin is deep (full thickness) then the natural healing is with scar tissue. Scars are pink when they are healing (immature scar) and turn lighter in color when fully healed (mature scar).

Unfortunately, scars can be unsightly. Some scars thicken (hypertrophic scar or keloid).  Other scars widen or develop spider veins within them.

Will my scars disappear?
Fortunately, the majority of scars heal well and fade over time, becoming less noticeable. Because scars and natural skin differ, they will never disappear completely.  Cover up cosmetics can help hide a scar.

What can I do about my unsightly scars?
Dr. Bryan Michelow cautions about treating your scar with surgical excision alone. "This may lead to a new, thicker, more unsightly scar then before."

The solution is to combine the expertise of the Plastic Surgeon with that of a "Seriously Skin" Specialist. Dr. Jennifer Kish offers additional specialized services with the aid of lasers, topicals and injectibles to manage those scars.

Some options available to clients include BBL (broad band light) treatment which allows for reduction of the scar’s pigment and brown hues.

Another option, the Micro Laser Peel, is used to reduce the raised effect of a scar and smooth out any Keloid scarring that may be present.

Finally, a Profractional treatment may be considered as the Profractional treatment allows the scar to heal in a more even fashion than a surgical procedure, reducing the size of the scar, and assisting the scar in replicating skin cells in a “non scarred” fashion.  

Ask about these special options:

Jennifer Kish, DO, FACEP  Seriously Skin, Chagrin Falls, Phone 440-247-3111
Bryan J. Michelow, MD,  Contemporary Cosmetic Surgery, Beachwood. Phone: 216-595-6800

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Blurred Lines

We know you don't want them.

Blurred lines are defined as lines that are just starting to appear but are not deep.  These small, fine lines may appear on the cheeks or around the eyes.

Attacking these "blurred" lines as soon as you notice them, may prevent them from getting deeper.

Plumping up the skin and enhancing cheek bones with dermal filler is one way to minimize the appearance of these nascent lines.

For optimal results, we often combine a Hydrojet facial, chemical peel or dermaplaning performed by our licensed estheticians. Dermaplaning utilizes a fine file to polish the skin thereby refining and brightening it's appearance.

Please ask us how we can help you

Office 216-595-6800

Bryan J. Michelow, MD

Gena O'Neill, Esthetician

Karli Mohr, Esthetician

more details at:

www,DrMichelow.com

PA Student Elective with Dr. Bryan Michelow - My Experience

The month-long rotation that I have spent with Dr. Michelow and his staff at Contemporary Cosmetic Surgery, Inc, has been the highlight of my clinical year, to date. Because this was one of my elective rotations, I was thrilled from day one to have an opportunity to learn about plastic surgery.  However, I never expected that I would gain so much hands-on experience.

This rotation has been unlike any of my other rotations.  From day one, Dr. Michelow and his office staff made me feel like a welcome part of the team and were willing to take the time to show me anything I wanted to learn.  My previous rotations had allowed me to take histories and perform physical exams; however, this rotation has allowed me to do so much more.
Rarely, did I find myself simply observing.  I have gained experience with documenting SOAP notes, pulling up injections, and assisting with excisions and other office procedures.

During my first week, I had the incredible opportunity to review suturing technique in the skills lab at Southpoint Hospital.  Dr. Michelow offers this additional instruction for his students and I am so grateful for the experience.  I received one-on-one instruction and then was able to practice what I had learned while the instructor checked back intermittently to give me feedback and to share other helpful tips.  This experience was so valuable to me because I have always been interested in surgery and I feel that it is where I would like to work in the future.  The suture lesson boosted my confidence and showed me areas in which I could improve.  I did not get the opportunity to practice much at all during my general surgery rotation; however, Dr. Michelow has allowed me to actively assist him on nearly every surgery.

This rotation has been unique in that it has allowed me to follow a patient’s case through the various stages of pre-op consults, surgery, and post-op office visits.  Through each stage, Dr. Michelow actively taught me about the importance of recognizing the uniqueness of each patient’s case.  More so than in any other rotation, I learned that patient education is vital and that what we learn from listening to patients is the most valuable tool of all.  .

I have gained invaluable clinical skill experience by finally applying what I had only read about and practiced in school.  I have been challenged to do more than in any other rotation,

and with that experience, I have gained more confidence in my abilities than ever before.  This rotation with Dr. Michelow has been such an incredible learning experience for me because

I have been encouraged to ask questions, to think critically, and to practice new skills each and every day.
It has been an incredible month and I can’t imagine a future rotation topping this one.

Maggie Deardurff
Physician Assistant Student
University of Mount Union
Alliance, OH
1/7/13 – 1/31/13

My Experiences as a Physician Assistant (PA) student - A great variety of patients

The last four weeks at Contemporary Cosmetics has been an amazing experience that I will never forget.

I was able to engage in a vast array of reconstructive as well as cosmetic procedures. I got the opportunity to assist in numerous different surgeries and in-house procedures from atypical nevus removals, facelifts, breast reductions and repairs of tendons. From dermatology to orthopedics and everything in between, I got to experience it all!

Dr.  Michelow’s patient population consists of male/female, pediatric/adult, and anything from head to toe. In my time at the practice and under close supervision,  I experienced an excision of a giant congenital nevus on a pediatric patient, removal of an atypical nevus of the foot, placement of a screw into a middle phalanx, and sewing of an extensor tendon back together, just to name a few. All of the procedures listed above were done with Dr. Michelow teaching me each step of the way.

The amount of trust Dr. Michelow has in his students is a great feeling. Not only was I being told and shown how something was done, I was involved in it!

Outside of procedures, I was able to understand the dynamics of an interprofessional workplace. When visiting Dr. Michelow’s hand clinic I got the opportunity to see how occupational and physical therapists work with patients.  It was interesting to see the progression and the effect of good follow-up care on a patient. For example, a patient we saw with a gunshot wound to the index finger was unable to move his hand at all and now is regaining motion. The progression is amazing to witness.

I benefited from a one-on-one suturing class at a local hospital, attended residency meetings, and had multiple networking opportunities. Dr. Michelow has even offered to be a reference when it comes time to apply for positions.

Although Cleveland was a long way for me to travel, Dr.Michelow and his staff made me feel right at home. The staff was extremely welcoming and eager to teach and show me how the office runs. Once I learned the system, I was taking history and physicals, helping with physical exams and finishing off by writing complete SOAP notes and setting follow-up appointments.

Coming into this rotation, I thought it was going to be all breast augmentations and tummy tucks, but I learned very quickly it was much more than just cosmetics. The knowledge I have gained is that of which I do not believe any other rotation has given me. The variety of different cases I saw made this a great learning experience that I will remember forever!

I highly recommend this rotation to all PA students interested in any type of surgery. Dr. Michelow and his staff have been wonderful and I will miss them so much! Thank you for an amazing opportunity!

Kinslee Scamaldo, PA-S
A.T. Still University
Mesa, AZ

PA-Student Elective - Highlights of the Day

Daily Highlights...

M- meeting the doctor and office staff and experiencing the hand clinic
T- seeing my first cosmetic procedures in office (fillers and muscle relaxants)
W-first-assisting Dr. Michelow in a few surgical cases
TH- first-assisting Dr. Green in my first cosmetic surgical experience
F- Excising of large basal cell lesion almost on my own and having the patient thank me as well as Dr. Michelow at the end was such an awesome feeling.

M-seeing a patient in the office after his Friday operation and checking the stitches that I placed
T- assisting with a sebaceous cyst removal in office
W- learning how to correctly present a history and physical exam for Dr. Michelow
TH- suture lab experience in which I received one-on-one teaching and observation of my suture technique
F- having my own operative patient in order to present my case presentation

M- assisting with an in-house nevus removal
T- draining post-operative breast seroma
TH- filling breast expanders up with saline
F- assisting 2 plastic surgeons in a large reconstructive case (bilateral breast  reconstruction with TRAM flaps)

M-seeing radial nerve palsy at the hand clinic
T- removing stitches that I had placed myself

Plastic Surgery Rotation II     
Brianna Fabiani
University of Mount Union
Alliance, OH
10/15/12- 11/8/12

A 4-Week Physician Assistant Elective in Plastic Surgery

The four weeks spent at Contemporary Cosmetic Surgery, Inc. are four weeks of my clinical rotations that I will never forget. 

As a PA student, I had the opportunity to work with and get to know an outstanding plastic surgeon and his amazing staff. Dr. Michelow has shown to be an excellent physician, who cares not only about his patients, but his students, and staff as well. He has extensive medical training and knowledge, which he is willing to share with all.

 This elective has been a great opportunity for knowledge growth, clinical skills, and patient encounters.  During my time with Dr. Michelow I was able to participate in many aspects of patient care and academic experiences.  They included:
- History and Physical examinations
- In office procedures: cosmetic fillers and muscle relaxant injections, wound care, I&Ds, punch biopsies, skin tag removal, suture placement and removal
- First assisting in reconstructive and hand surgeries presenting in the OR
- Observation and evaluation of many different skin pathologies including melanoma, basal cell carcinoma, and squamous carcinoma
- Attending a clinical suturing lab
- Accompanying Dr. Michelow to the residency meeting at University Hospital
- Participating in valuable research, allowing me to create a survey on cosmetic procedures

All students considering a plastic surgery rotation would be extremely lucky to have an opportunity with Dr. Michelow.  He is a wonderful and patient teacher who constantly provided me with the best possible clinical experience.  He was always teaching, presenting, and walking me through any procedure and patient care. 

With that being said, I highly recommend this clinical site as an elective rotation for all students interested in a plastic surgery rotation.

Hayley Griswold PA-S
University of Mount Union

Physian Assistant Elective in Plastic Surgery

Contemporary Cosmetic Surgery, Beachwood, OH
Preceptor- Dr. Bryan J.Michelow

Dr. Michelow is an outstanding plastic surgeon with extensive medical training and knowledge, and his staff at Cotemporary. Cosmetic Surgery are extremely welcoming and accommodating. 

An elective rotation with Dr. Michelow has proven to be an invaluable experience, and I have been given the opportunity to participate in a variety of aspects of patient care including:
        -Performing H&Ps
        -Writing and recording physical exams and SOAP notes on their computer
          system
        -Gaining experience evaluating and treating various skin pathologies
        -Gaining experience evaluating and treating various hand injuries
        -Gaining extensive knowledge about various skin injections, including
          the use of neurotoxins and dermal fillers for cosmetic use
        -Participating in wound care, dressing changes, etc
        -Performing and assisting with skin excisions, I&Ds, punch biopsies
         and other small office procedures
        -First assisting in major cosmetic, reconstructive and hand surgeries

A rotation with Dr. Michelow has also given me various academic opportunities including:
        -Attending a clinical skills suturing lab to learn and practice various
         suture techniques
        -Accompanying Dr. Michelow to a variety of conferences and talks, including
         residency meetings at University Hospital, Tumor Board Review through
         Cleveland Clinic, and Risk Management dinners
        -Participating in clinically valuable research, allowing me to create a
          PowerPoint presentation about the safety and efficacy of neurotoxins and
         dermal fillers

Dr. Michelow is a wonderful and patient teacher. He is genuinely interested in providing students with the best possible clinical experience, and he makes the student a top priority in his practice. 

As a PA student at Contemporary Cosmetic Surgery, he gave me various opportunities to branch outside his office by assisting fellow plastic surgeons on interesting cases. He did not simply use me as an extra pair of hands in the office, but rather gave me the freedom to actively participate in patient care and stressed the importance of maximizing my clinical education. 

I highly recommend this elective rotation to any PA student interested in plastic surgery or wishing to gain more surgical training.  I will miss the entire office!

Sharon Santangelo, PA-S
Saint Francis University
Loretto, PA