A ^Retired Plastic Surgeon's Notebook

Got sunscreen in your glove box?  You should!

 This is an ABC news report written by Serena Marsh and edited for length by me.  This was originally posted in 2012.

Sunny Side Old: Pic Reveals Sun’s Aging Effects

William (Bill) Edward McElligott is two different ages, 66 and 86 yeaars 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.

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.

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.”

Thanks for reading.  And do you have a favorite sunscreen?  Send me an email and let me know. lsowder@madisonplasticsurgery.net

Dr. Lisa Lynn Sowder

Follow me on Instagram: @sowdermd and @breastimplantsanity

Sparky is especially trained to sniff out illegal sunscreen. Woof.

This is an article from the May/June 2015 King County Medical Society Bulletin.  It’s a little long and technical but just hang onto that attention span and read it!

Packing a Sunscreen Souvenir

Tourists Grab UVA Treatments Common Elsewhere, Illegal Here

By Barbara K. Gehrett, M.D.

Some international travelers are returning with pharmaceutical souvenirs – new UVA sunscreens available in Europe, Canada, Mexico, and other countries and not yet approved in the United States.

Ninety-five percent of the solar UV radiation that reaches earth is UVA.  It has a wavelength between 320 and 400 nanometers and is present during all daylight hours, summer or winter, cloudy or clear.  UVA passes through glass and penetrates deep into skin.  It is responsible for more damage to basal keratinocytes in the epidermis than UVB.

Most UVB damage occurs in the superficial layer of the epidermis, producing suntan, sunburn, and aging skin.  Protection from UVB with sunscreens reduces the risk of non-melanoma skin cancers.

Two short-acting, barrier-type UVA sunscreens have been approved for use in the U.S.  These are zinc oxide and oxybenzone.  Dermatologists argue that their protection is limited and requires repeated application because they break down quickly.

Ecamsule is a longer-acting “chemical filter” made by L’Oreal and is one component of a U.S. approved lotion, Mexoryl.  The FDA turned down the application to release ecamsule as an over-the-counter UVA sunscreen, although it has been available in Europe since the late 1990s.  It is regulated there as a cosmetic, which has a different standard than the drug category it falls into in the U.S.  All sunscreens in Europe must give both UVA and UVB protection.

Eight UVA sunscreen products have been languishing in line (one since 2003) for FDA consideration.  Congress and President Barack Obama attempted to pressure the FDA by passing the Sunscreen Innovation Act in December of 2014.  This new law requires the FDA to issue an approval or disapproval ruling within 60 days of receiving a complete application for sunscreen.   All eight of the new UVA sunscreens were expeditiously disapproved by the FDA early in 2015.

The FDA wants long-term data on safety before approval will be given.  Typically this means two Phase 3 clinical trials, which are expensive and time-consuming.  It is possible ;that future data on skin cancer protection from other countries would move the agency.  Or perhaps ;the procedural review taking place at the agency will result in a different set of criteria for sunscreens.

In the meantime, U.S. travelers stocking up on sunscreen  when they are outside the country are violating the Food, Drug and Cosmetics Act by importing unapproved drugs.  According to WebMD, the FDA does not generally pursue violators, unless the quantities involved are egregious.  One other work of warning:  online purchases should be made with caution, because of international counterfeiting of drugs.

Thanks for reading!  And keep using that lousy U.S. approved sun creen.  It’s better than nothing.   Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon spends a week in Hawaii and returns with no tan lines!

Last week I attended the annual meeting of the Northwest Society of Plastic Surgeons on the Big Island of Hawaii.  And contrary to popular belief, I actually sat in a conference room for about 5 hours a day and actually learned how to be a better surgeon.  The other 7 or 8 hours of daylight presented a bit of a challenge to a sun shunning person of pallor such as my Germanic self.  But it can be done.  Here are my rules:

1. Slather with sun block first thing after that morning shower.  The spray on stuff by Neutrogena works great.
2. Wear a hat and sunglasses.
3. Lounge in the shade.  Walk on the shady side of the street.  (Duh)
4. Wear a rash guard while snorkeling after respraying yourself with sun block.
5. Spend the few hours of the really nasty mid-day sun in the bar.  (Duh)  Drink cocktails with umbrellas.  (Duh)
6. And most of all, embrace your pallor.  I hear that the Hawaiians and Southern Californians refer to us as “Chalk People.”  Bring it on.  I won’t be spending my golden years tending to my skin cancer.
7. Oh, and look for my new book, “Fifty Shades of Sun Damage” soon to be a major motion picture staring this dude with the bad skin.

Thanks for reading!  Dr. Lisa Lynn Sowder

Treat acne now to avoid scars later.

If, like me, you are a fan of the cable T.V. show “Justified” you recognize this man as Johnny Crowder.   I find him very attractive despite his really severe acne scarring.  Maybe it’s because he is the quintessential bad boy or maybe it’s because he has such a soft heart despite being a total sociopath.  Anyway, he was killed last season by his even more bad ass cousin, Boyd Crowder so I won’t be able to enjoy his handsome mug anymore.  But this post is not about my taste in men but about acne scars.

Acne is often thought of as just one of the many challenges of adolescence and in many cases it is.  Mild cases can often be controlled with over-the-counter treatments and usually the acne subsides once the hormones have leveled off.  But for some, acne can be a devastating disease.  When the acne lesions are deep and cystic, they can destroy the normal fat layer under the skin and cause deep permanent scars as in David Meunier, the actor who plays Johnny.   Acne scars have not kept Mr. Meunier from  finding success but they may limit his roles somewhat.  He may find himself cast more frequently as a bad guy.

So if you or someone you know has out of control acne, get thee to a dermatologist.  Those pesky “zits” of today can turn into the life long scars of tomorrow.  Oh, one more thing – treating acne scars is really difficult and only partially effective.  It’s much better to prevent them in the first place.

Thanks for reading!  And Johnny, I miss you!  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon discusses a common and annoying skin condition – Keratosis Pilaris.

Pilaris keratosis – annoying but harmless.

Earlier this week I saw a young woman in my office requesting breast augmentation.  During the consultation, she also wanted me to take a good look at her upper arms and anterior thighs.   She had scattered teeny, tiny little red and while bumps.

Now there are many, many dermatologic conditions that I know very little about but her condition,  keratosis pilaris , is one I am very familiar with because I have it.The little bumps seen in keratosis pilaris are caused by plugged pores.  This condition seems to be hereditary (thanks, Mom) and usually shows up around puberty and tends to get better with age.  The most common areas affected are the upper arms, the thighs, the cheeks and the other cheeks.

Most cases of keratosis pilaris do not require medical attention because self care is often very effective.  There are many over the counter ointments that contain some type of acid, be it lactic acid, glycolic acid, salicylic acid or urea.   These mild acids break up the plugs of keratin that block the pores.  These ointments need to be used regularly to maintain their efficacy.  Sephora makes a cream specifically for this keratosis pilaris, KP Duty.  I’ve heard it works very well. And as a person ages, the keratosis pilaris usually just sort of disappears.  Just one of the many wonderful things that happens as we get older.  Really! So if you have keratosis pilaris, start with some self treatment and be glad you don’t have something worse!

Thanks for reading.  Dr. Lisa Lynn Sowder

 Seattle Plastic Surgeon discusses “Bunny Lines”

I saw a patient today who wanted treatment for those funny little horizontal wrinkles on the nose that we plastic surgeons refer to as bunny lines.  She was surprised that I recommended Botox instead of a filler.

Botox works very well for bunny lines because these creases are caused by the underlying procerus muscle.  This muscle allows for that expression that people have when they smell something really, really bad.  Botox weakens the muscle and the wrinkles smooth out over several weeks after injection. 

Filler, such as Juvederm or Restylane could be used to fill in these creases but filler woud not treat the underlying cause and could make the bridge of the nose look a little bulky. 

Botox and fillers are both “injectables” but they treat wrinkles in completely different ways. 

Thanks for reading.  Dr. Lisa Lynn Sowder

Pasty white Seattle Plastic Surgeon shares her view on tanning bed restrictions.

Some of the girls have spray on tanned legs but some of them have obviously been spending time in an indoor tanning salon and, as a physician, it drives me nuts. 

 The incidence of Malignant Melanoma has been going up, up, up in the past couple of decades and it’s rising the fastest in the same group that spends the most time in indoor tanning salons – young women. 

 Many countries and some states have placed age restrictions on indoor tanning.  Brazil has an outright ban on indoor tanning.  I’m not one to advocate a nanny state, but I do think that we need to protect children from their own bad choices when the stakes are very, very high.  Isn’t that why we don’t sell children cigarettes and alcohol? 

 What do you think?  Should a 12 year old be able to waltz into a tanning salon to spend her allowance on a tanning session?  Should I say something to the parents of these tanned girls?   Should I spray paint my daughter’s legs?????

 Thanks for reading!  Dr. Lisa Lynn Sowder

Do you have a child with severe acne???  An ounce of treatment now is worth a ton of scar revisions later.

Left: Before a bazillion procedures. Right: After a bazillion procedures.

I have two children in high school and I often am asked for advice regarding acne.  I am not a dermatologist nor do I play one on T.V. so do not expect any advice as to the latest therapies for acne.  I do have advice, however, on whether or not one should seek therapy.   So here goes.

If the zits are small and superficial, there will likely be no lasting damage and whether or not to seek anything other than over-the-counter treatment is really a matter of how much the zits bother your child.  BUT if the zits are deep (so called cystic acne), your child needs to get treatment YESTERDAY. 

 The problem with cystic acne is that it causes inflammation deep under the skin and can result in very bad scarring that can be devastating and permanent.   And it’s not just the scarring that is an issue.  The inflammation can also cause atrophy of the fatty layer under the skin and cause sinking in of the face. 

 The example on the right shows both superficial scarring and also some deeper scarring and atrophy.  This is a mild case.  If this were a man, he probably would not have sought treatment but this is a young, beautiful, fine featured woman and this post acne scarring affects her self esteem and also results in her spending a lot of time every morning trying to cover this up.   

She an I got to know each other very, very well over about two years of procedures that included fat grafting, skin resurfacing, excisional scar revision and filler injection.  It was a long process but worth it for both of us.  She can now get on with her day without the prolonged fussing with cover-up and I just loved the bright smile on her face at her last visit. 

 Not all plastic surgeons are well suited to treat these patients because it involves a lot of patience (which I for some reason have in abundance) and a lot of hand holding. 

 But the real message here is that if you know someone with deep, cystic acne who is not under the care of a dermatologist, do what you can to get them proper care.  What seems like just a minor, cosmetic issue can be a major, difficult to treat problem later. 

Thanks for reading!  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon blogs about the lessons learned in the play, Pygmalion, now playing at Seattle’s Intiman Theater.

Mark Anders as linguist Henry Higgins and Jennifer Lee Taylor as Eliza Doolittle. Her décolleté is so lovely, he dare not look!

Last night I soooo enjoyed attending Pygmalion at Seattle’s Intiman Theater.  There is something about live human beings on stage telling a story through words and action that just touch my soul so much more than film or television ever does. 

 Pygmalion, as most of you probably know, refers to the story of the artist who fell in love with his own sculpture of the “perfect woman”. 

The play, written by George Bernard Shaw and made into the musical My Fair Lady, tells the story of Linguist Henry Higgins turning the gutter snipe Eliza Doolittle into a Duchess.  In the end of course, he learns as much from her as she does from him.  It’s a great story of class and money and manners and empathy and for the plastic surgeon in the audience, the importance of sun protection on the ever important  décolleté .  

The  décolleté  is so often exposed to the sun and, unlike the face, is not amenable to deep chemical peels or laser treatments to treat the sun damage.  Therefore, prevention is paramount.  I recommend adding quick spray of Neutrogena spray-on sun block every morning to the décolleté  to every woman’s morning skin care routine.  It takes but a second or two and helps maintain skin health in this most important female landscape. 

I also highly recommend seeing this delightful play!

Thanks for reading.  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon shows off a GREAT NON-SURGICAL RESULT – take a look at this.

And take a look at these photos.  Her skin quality is so much better and the shape of her jaw line and chin is so improved and her wrinkles —- what wrinkles?????