Skin Deep

Vanity takes a backseat to necessity when cosmetic skin surgery saves lives

By Pam Lettie

For Sgt. Robert Bartlett, reconstructive plastic surgery allowed him to speak. He can feel his wife’s kisses. He doesn’t drool.

Bartlett is a calvary scout sniper who was riding in a truck in Iraq when a bomb hit the truck, taking off half his face. Bartlett was missing almost all of his bottom lip and lower eyelid, the front of his nose, plus his left eye—to say nothing of the injuries to the rest of his body. For three weeks, the soldier was unable to communicate. He died and was revived three times.

Bartlett regained his ability to talk and even speaks to large groups, making sure that the war—and our soldiers—are not forgotten. He’s lost count of the number of surgeries to fix his face; 15, maybe
20 operations.

For most of us, plastic surgery will not make such a dramatic difference in our lives. Still, many of the procedures are more than skin deep, some offering life-saving treatments for cancer. Technological advances may grab the headlines, but solid centuries-old techniques remain the doctor’s regular tools. When analyzing sun damage, removing cancerous moles, reducing the appearance of scars and using skin grafts, physicians combine old and new technology to serve patients.

Sun Damage Reversal
Board-certified dermatologist Dr. Nicole Hayre of the Cosmetic Dermatology Center in McLean says old-fashioned evaluation works best to analyze sun damage. She looks at the patient’s skin. Brown spots, freckles, dilated blood vessels or red marks, large pores, poor skin texture and wrinkles are signs of damage.

For a solution, she often turns to a device called “Portrait.” Hayre is cautious about new technologies. She doesn’t bring anything into the office that she wouldn’t use personally.

“It’s better to have a wait-and-see attitude. You really want to know what the probability is of having a side effect.”

Portrait looks like a handheld laser fired at the skin, but uses plasma, an energized gas.

Through a controlled heating of the upper layers of skin, Portrait induces the lower layers of skin to build new collagen and repair itself. The intensity can be adjusted for a single high-energy treatment or a series of low-energy treatments depending on the needs of the patient—lifestyle, plans, family, skin quality, extent of sun damage, patient’s age.

It takes about four months after the procedure to start looking amazing, but patients improve for up to a year, Hayre says.

Andrea Orlando decided to have a high-energy Portrait procedure over Thanksgiving 2007. “My chin and around my mouth—the lines around the smile lines—looked really bad to me. I had had moles removed when I was younger, and the scar tissue puckered. I was really self-conscious. The procedure is not like a walk through the park, but it’s not painful. When it’s over, you feel hot, like a bad sunburn, but that goes away after a couple hours. Then you have beautiful baby skin. It’s a little pink. It’s like being a teenager again.”

But the change for patients can be more than skin deep. “I’ve had some really big transformations over the years in the office. I’ve seen people come in with new hair styles; they’ve lost weight, wearing more fashionable clothing,” Hayre says.

“It just makes me feel great. I love doing this.”

Portrait Resurfacing
Best candidates: On high energy, patients with significant damage, more laxity in skin and deeper lines benefit most. On low energy, almost any patient could benefit.
How it’s done: Patient sits with hydrating gel (for low energy) or numbing lotion (for high energy) on his or her skin for an hour. After washing gel off, the laser is pointed at one section of skin after another.
Length of surgery: 15 to 20 minutes
Recovery time: Sunburn feeling for one to three hours. Avoid sun for a couple days. On high energy, patients usually stay in for a week. On day five or six, sloughing removes skin that looks like a mask, leaving pink skin underneath. On low setting, there is no downtime.
Cost: $4,000 to $6,000
Potential side effects: Pink coloration, peeling or a sunburned feeling. Scarring is always possible, but uncommon, if patients follow instructions.

Mole Removal
As Hayre works to repair the visible effects of the sun, Dr. Martin Morse, a Great Falls plastic surgeon, attacks the most serious cancers that are products of sun. The American Cancer Society says that most of the more than one million cases of skin cancer are sun-related. Skin cancer is the most common type of cancer, although it is treatable when caught early.

The majority of skin cancers appear as a lesion on the skin, but can grow out of pigmented skin, such as a mole. Most moles are harmless, but certain symptoms—increased size, itching, ulcerated skin, color change and irregularity of shape—might prompt a trip to the dermatologist or family doctor to biopsy and check for cancer. With a diagnosis of cancer, the patient may be referred to a specially trained dermatologist for a Mohs excision or to a plastic surgeon for excision and reconstruction.

Morse usually sees patients on referral from a family doctor or dermatologist after the patient has a diagnosis of cancerous/precancerous cells or after a Mohs surgery for reconstruction. He removes cancerous lesions, including lesions found on moles. Morse warns patients that, while insurance companies will cover mole removal if it is cancerous, paying to remove a benign mole falls on the patient.

For the most common skin cancers, basal and squamous cell, the surgeon removes a small area around the legion. This procedure is often done in the office with local anesthetic. But for more aggressive cancers—melanoma or a larger basal- and squamous-cell legion—a wide local excision would be Morse’s recommended approach. The wide local excision usually takes place in a hospital and requires some reconstruction to put the skin back together, either with stitches, a flap or skin graft. A pathologist reviews four points and the base of the excised lesion to make sure there is a cancer-free margin. A final review of the surrounding tissue takes place within a couple weeks, but usually the margins are free of cancer. If not, another excision may be called for.

While there are new laser treatments, Morse doesn’t recommend those. They destroy the lesion, so there is no way for the pathologist to determine whether the margins are clear of cancer.

Wide Local Excision
Best candidates: Patients referred by a physician who has performed a partial biopsy
How it’s done: Mole or lesion plus an area around it is removed.
Length of surgery: 45 to 90 minutes
Recovery time: One month to heal 90 to 95 percent. Stitches are removed in about a week; avoid sun, and wear sunscreen for six to 12 months.
Cost: $1200 for lesion removal and closing the wound
Potential side effects: Risk of infection; about 5 percent of the facial grafts don’t take; also skin may not match in texture or color.  Infection, bleeding or scarring. Risks specific to this procedure include recurrence and injury to associated blood vessels or nerves.

Skin Grafts
For skin cancer patients, repairing the aftermath of surgery can be as simple as letting a site heal on its own or suturing it. For cases where that isn’t enough, a surgeon can bring a flap of skin from nearby. Skin grafting, moving skin from one part of the body to another, is the last resort.

A number of Dr. Steven Rotter’s skin-cancer patients have benefited from grafting, as have patients of Morse. Of the Center for Skin Surgery, Rotter’s been performing dermatological surgery for 16 years, and has his own outpatient surgical hospital, the Skin Cancer Outpatient Surgical Hospital, where he performs the surgery.

Rotter describes skin grafting as a procedure that’s been around for 100 years and is still effective in helping patients. Skin grafts fall into two types: split and full thickness. Split-thickness skin grafts can cover large areas. The cosmetic result is not as good or as durable, but only leaves a rope burn from the area where the skin is removed. A full-thickness skin graft uses the full thickness of the skin, is best for cosmetic reconstruction and is what Rotter uses almost exclusively.

The surgeon looks for inconspicuous skin that matches missing skin. He numbs the area and cuts out the skin that needs to be moved. From there, the skin is trimmed to fit the area of missing skin, then stitched in place.

Joe Whitaker of Fairfax Station had severe skin cancer on his ear. After having the cancerous legions removed with a Mohs surgery, Whitaker was missing the outside edge and bottom of his ear. After allowing the area to heal two to three months, Rotter did the first of two skin grafts to repair the ear.

Whitaker describes his cosmetic-surgery experience this way: “It’s been two skin grafts, one on the top and front of the ear, and one on the back. I literally didn’t have an ear until he did this. He did a great job, given what the problem was. I was pleasantly surprised. I’ll tell you, look at the picture of my ear from what I left with after surgery and what I have now. It’s an amazing difference. My ear was penned down, but now it looks like a normal ear.”

The most painful part of the process was a local anesthetic used to numb the site, Whitaker says, and the biggest inconvenience was that he couldn’t take a shower for seven days after each graft.

Skin Grafts
Best candidates: Patients whose wounds are too big for stitches or a flap; those with a contracted scar that needs to be expanded
How it’s done: Skin is moved from one area to another by cutting and stitching.
Length of surgery: 20 to 45 minutes
Recovery time: Four to six weeks for area to look good
Cost: Medicare pays $500 or so as a reimbursement, Rotter says.
Potential side effects: Risk of infection; about five percent of the facial grafts don’t take; also skin may not match in texture or color.

Scar Revision
When a patient comes to Dr. Behzad Parva of Leesburg to fix a scar, educating that patient is Parva’s first thought. He wants to be sure that clients realize that a plastic surgeon can’t make a scar go away.
“We are not removing a scar, we’re revising it. We’re minimizing
its appearance.”

Scar revision was the third most common reconstructive surgery in the United States in 2007, according to the American Society of Plastic Surgeons. Parva evaluates the location of the scar and the effect of surrounding tissue and structures. The visibility of a scar is determined by irregularity in skin, shadows cast and the effect of surrounding facial structures. For example, a tight scar might pull on an eye and draw attention.

For some scars, the direct approach of reopening the scar and restitching it could make it into a finer line.
Other scars require more elaborate tissue rearrangement. A skilled surgeon makes geometric incisions to free skin on as many as three sides, then shifts surrounding tissue to minimize scars, to conceal them in a natural skin line or to alleviate tightness.

The scar-revision technology has been around for centuries. The procedure is usually performed under local anesthetic in the office. For more significant scarring, general anesthesia may require a surgical setting.
Patient Roger Aaron of Winchester came away pleased with the results. Cosmetic surgery earlier in his life left Aaron with a large scar on his face. He tried permanent makeup—a form of tattooing—but that only made it look worse in his case.

“It just widened tremendously over the years. It turned white, you know, as it stretched. It got worse and worse. Dr. Parva did a marvelous job. He does it right in the office with a local anesthetic. They make a cut at the scar area and pull the top layer of skin over. I’m just really delighted not to have this scar.”
Parva would be quick to point out that, while the scar is still there, it’s now disguised by the face’s natural structure.

Scar Revision
Best candidates: A scar needs to be at least a year old. Otherwise, it’s still healing.
How it’s done: The physician makes an incision. The freed skin is shifted to make the scar less noticeable.
Length of surgery: For a scar that is a couple inches long, less than 45 minutes.
Recovery time: Stitches and dressing need to be monitored for about a week. Patients need to use sun block and a scar-minimizer, such as a topical silicon or vitamin-E oil.
Cost: Five hundred to several thousand dollars, depending on the size of the scar and whether general anesthesia is needed
Potential side effects: Risk of infection. For extensive scars, the scar might separate or not heal well and require wound care. Diabetics or smokers have higher risk of complications.

Tags: cosmetic, Health & Beauty