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by James E. White, M.D., F.A.C.S. osmetic surgeons combine knowledge, surgical skill, technical expertise and ethics to achieve their goal of providing aesthetic enhancement for their patients. When choosing a cosmetic surgeon it is important to select a cosmetic surgeon who is board certified. In most states it is legal for any physician who holds a valid medical license, with or without surgical training, to practice cosmetic surgery. Board certification is important because it makes certain that your cosmetic surgeon has the training, qualifications and experience needed to perform your cosmetic surgical procedure safely and skillfully. A board certified cosmetic surgeon has greater insight into your needs, has knowledge of state-of-theart techniques and the surgical skill and judgment to recommend and perform the cosmetic surgical procedure that will enhance your appearance effectively and safely. Having said that, board certification does not equal quality care or quality outcomes. Having a Tennessee drivers license does not make one a good driverit only verifies that they have successfully completed the examination and have been issued a license to drive. In order for a surgeon to become board

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WOMAN'S WAY - November 2011

Why is Cosmetic Surgery Board Certification important?

certified in any medical specialty, they must go through a long demanding process that takes years to complete. The American Board of Cosmetic Surgery [ABCS] is the only certifying board that exclusively tests a surgeons knowledge and experience in cosmetic surgery. Surgeons develop their cosmetic surgical skills through post residency training and experience. The point is that a cosmetic surgeons skill and ability will depend on the surgeons cosmetic surgery training and experience, not on core board-certification. The number of people seeking cosmetic surgery has grown rapidly over the past several years. As part of a greater focus on appearance, people are turning to cosmetic surgery as one means of enhancing their appearance. At the same time, more and more doctors are practicing cosmetic surgery. Given the growing number of cosmetic surgery patients and the highly competitive pool of doctors performing cosmetic surgery, it is vital that you obtain accurate information regarding cosmetic surgery and the doctors who perform it. Before you undergo cosmetic surgery, it is important you become informed about the doctors education, training, experience and proven competence with respect to the specific procedure you seek. Cosmetic surgery may be performed in various facilities such as hospitals, surgical centers and office settings. An accredited surgical facility must meet certain minimum standards to obtain and maintain its accreditation. to you the risks and possible complications, and potential side effects, including the pros and cons of

Before the surgery, your doctor should explain the procedure. In addition, ask about the surgeons privileges in an accredited surgery center or a hospital to perform cosmetic surgery. As for how you should choose a cosmetic surgeon or cosmetic surgical center--- You should do the research locally and online. You can perform a standard internet search with the name of the doctor or the procedure about which you would like to receive more information. What do you see online? Negative or positive feedback or reviews. Make sure that your surgeon has a good reputation, a strong background in the surgical field, and above ALL ... that he or she produces good results. Training is important; board certification is important; but skill, judgment and artistic detail are evidenced by experience and outcomes not board examinations. n Dr. James E. White is board certified in General Surgery by the American Board of Surgery, in venous disease by the American Board of Phlebology, and in cosmetic surgery by the American Board of Cosmetic Surgery. He is a Fellow of the prestigious American College of Surgeons, a Diplomat of the American Board of Phlebology, and a Fellow of the American Academy of Cosmetic Surgery. Voted Best of the Best in Cosmetic Surgery, in 2010 and 2011, his office, Advanced Surgical Concepts, 7446 Shallowford Road, Suite 205 in Hamilton Office Park, is fully accredited. He offers a variety of cosmetic procedures including laser skin resurfacing, facial fillers, minimal invasive cosmetic surgery and Botox. He may be contacted at 423-648-4011.

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by James E. White, M.D., F.A.C.S. urgeons are doing more than just checkups in their offices these days. Advances in medical technology have made it possible for physicians to perform more advanced and more complex surgical procedures in their offices. Whether it is vein surgery, skin cancer excisions, tummy-tuck, breast augmentation, facelift or a complex biopsy, these procedures can be completed in an office-based surgery suite. Since most patients want to avoid an overnight hospital stay after surgery, ambulatory surgical procedures have become very popular. Thats why almost one-half of all surgeries are now being done in an outpatient facility, either connected to a hospital or in a separate surgical center. More recently, though, there has been a growing trend for surgery to be done right in a doctors office. Office-based surgery can offer the convenience of having a procedure done in a more comfortable setting with a quick return home. Charges associated with ambulatory surgery are less than fees charged at a large hospital. Charges associated with ambulatory surgery completed in an office setting are substantially lower. The same anesthetic techniques used in hospitals and ambulatory surgical centers are used in office-based surgery. They include: Local anesthesia, which provides numbness to

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WOMAN'S WAY - October 2011

Office-based surgery
a small area of the body, such as a dermatologist might use to numb the skin around a mole before removing it. Monitored anesthesia (sedation/analgesia), during which a patient receives medications that relieve pain and make the patient drowsy. During surgery, the patients vital signs, including heart rate, blood pressure and oxygen level, will be watched closely in order to avoid sudden changes or complications. Regional anesthesia, which can include spinal blocks, epidural blocks or extremity blocks. Spinal and epidural blocks involve interrupting sensation from the legs or abdomen by injecting local anesthetic medication in or near the spinal canal. Other blocks can be performed for surgery on your extremities, or limbs, blocking sensations from the arm or leg. General anesthesia, which involves the total loss of consciousness, pain sensation and protective airway responses. From the simple removal of a mole to breast augmentation/reduction, liposuction, hernia repairs or knee arthroscopies, a rapidly growing number of surgeries are being performed in doctors offices rather than in hospitals or ambulatory surgical centers. More complex procedures are likely to become common in the near future. At last review in 2005, an estimated 10 million procedures were performed annually in doctors offices twice the number of office-based surgeries performed in 1995. Today, about one out of 10 surgeries is performed in a doctors office. In considering your options when surgery is advised, here are some items that you should consider before undergoing surgery in a doctors office. Ideally, anesthesia during larger surgical cases should be

delivered or supervised by a person extensively trained in anesthesia techniques, like a Certified Nurse Anesthetist or Anesthesiologist. Anesthesia needs are determined by your medical condition as well as by the type of operation you will have completed. A doctors office should have the necessary emergency drugs, equipment and procedures in place to care for you in the rare event of a life-threatening complication. Many states require licensing or accreditation by a recognized agency. These agencies regularly inspect such offices to ensure that minimum standards of patient care and safety are met. Ask your doctor if their surgical office suites have been accredited. n Dr. James E. White is board certified in General Surgery by the American Board of Surgery, in venous disease by the American Board of Phlebology, and in cosmetic surgery by the American Board of Cosmetic Surgery. He is a Fellow of the prestigious American College of Surgeons, a Diplomat of the American Board of Phlebology, and a Fellow of the American Academy of Cosmetic Surgery. Voted Best of the Best in Cosmetic Surgery, in 2010 and 2011, his office, Advanced Surgical Concepts, 7446 Shallowford Road, Suite 205 in Hamilton Office Park, is fully accredited. He offers a variety of cosmetic procedures including laser skin resurfacing, facial fillers, minimal invasive cosmetic surgery and Botox. He may be contacted at 423-648-4011.

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by James E. White, M.D., F.A.C.S. any areas of the body can accumulate fat that is hard to lose, in spite of a healthy diet and vigorous exercise. The neck is one such area. Fat deposits in the neck can detract from the appearance of the entire body, making a younger person seem older, or a fit person seem out of shape. The face and neck are usually the first features we notice when we meet someone new, so improvements in this area can create a dramatic change. A firm, trim neck gives the face a more youthful look. Sometimes just having neck liposculpture completed provides an incentive to make healthier lifestyle choices, and maintain fitness in the rest of the body. Neck liposculpture can be completed in an office surgery setting using local anesthesia with sedation. Oftentime, laser application is completed to the undersurface of the skin just prior to liposuction. The laser is thought to cause thermal modulation to the skin resulting in skin tightening. Liposuction can be completed solo or with the assistance of vibration techniques. During the initial consultation, your surgeon will talk with you about the changes you would like to make in your appearance. He should explain the different options

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WOMAN'S WAY - September 2011

Neck liposculpture
available, the procedure itself, its risks and limitations, and costs. You should have a physical examination to evaluate your overall weight, your skin and muscle tone, and the pattern of distribution of fat deposits. Photographs should be completed for before and after comparisons. Be sure to ask all the questions you have about the procedure, and ask to see photographs of the doctors recent patients, before and after treatment. Learn everything you can about your options, risks and benefits. Before surgery, the surgeon will mark the precise areas of the body where the fat is to be removed. During the procedure, the surgeon makes tiny incisions [1-2mm in diameter] in the skin, typically in the crease just under the chin or behind the ear lobes and low in the neck. A thin tube called a cannula is inserted into the fatty area. The cannula is used to break up the fat deposits and sculpt the area to the desired proportions. The newest liposuction techniques involve the placement of a laser fiber or an ultrasound probe through an open-ended cannula. Laser energy or high frequency ultrasound energy is delivered directly to the fatty tissues. This focused high level energy causes the fat to be emulsified making suction removal easier. The unwanted fat is removed with a high suction vacuum, leaving the skin, muscles, nerves, and blood vessels intact. The high level energy delivered by the laser fiber or by ultrasound can also be used to heat the undersurface of the skin thus leading to skin retraction and skin tightening. Liposuction can give this area a new streamlined contour, enhancing the effect of facial features and

improving the facial profile. Patients who have been selfconscious about their bulging necklines often feel more comfortable wearing a range of clothing and jewelry styles after liposuction. Neck liposuction is minimally invasive with limited scars, produces consistently good results, and has a particularly high satisfaction rate among patients. n Dr. James E. White is board certified in General Surgery by the American Board of Surgery, in venous disease by the American Board of Phlebology, and in cosmetic surgery by the American Board of Cosmetic Surgery. He is a Fellow of the prestigious American College of Surgeons, a Diplomat of the American Board of Phlebology, and a Fellow of the American Academy of Cosmetic Surgery. Recently voted 2010 Best of the Best in Cosmetic Surgery, his office, Advanced Surgical Concepts, 7446 Shallowford Road, Suite 205 in Hamilton Office Park, offers a variety of cosmetic procedures including laser skin resurfacing, facial fillers, minimal invasive cosmetic surgery and Botox. He may be contacted at 423-648-4011.

WOMAN'S WAY - August 2011

Wrinkle, wrinkle, go away; don't come another day

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by James E. White, M.D., F.A.C.S. s we age, our faces begin to show the effects of gravity, sun exposure and years of facial muscle movement, such as smiling and chewing. The underlying tissues [collagen and elastin] that keep our skin looking youthful and plumped-up begin to break down with age. As we continue to use our facial muscles, the thin stiffened skin shows signs of wrinkles often leaving laugh lines, frown lines, smile lines and facial creases over the areas where this muscle movement occurs. Some of the wrinkles are related to genetics; but most are related to sun exposure. Facial soft-tissue fillers can help fill in these lines and creases, temporarily restoring a smoother, more youthful-looking appearance. When injected beneath the skin, these fillers plump up creased and sunken areas of the face erasing years away. Injectable fillers may be used alone or in conjunction with a resurfacing procedure, such as a laser skin treatment, chemical peel or a recontouring procedure, such as liposuction, fat transfer or mini facelift. Facial fillers or injectable fillers are primarily used to improve the appearance of the skins texture. They can help fill out deep facial wrinkles, creases and furrows, sunken cheeks, skin depressions and some types of scars like acne pits. They can also be used to add a fuller, more sensuous look to the lips and improve lipstick lines. Many fillers are available on the market; common fillers include: Restylane, Radiesse, Jeuvaderm, Sculptra and Selphyl. Each of the listed fillers are made from different substances and have different characteristics and modes of action. Effects and length of time effect are greatly different for each of the common fillers. Botox is not a filler; but rather a neuromuscular blockade medication. It is used in conjunction with fillers to help smooth creases caused by overactive muscles (such as forehead wrinkles, crows feet and frown lines). The fillers help lift the cracks in the skin, while the neuro-blocker causes the underlying facial muscles to be weak. The weakened muscle is then not able to contract exposing the wrinkle. Excess facial skin, fatty deposit or neck skin is more appropriately treated by skin tightening surgical and non-surgical face and neck lifts or forehead lifts in conjunction with fillers and or neuromodulators. Depending on the type of facial filler used, the results may last anywhere from a few months to a year and a half or more. Facial rejuvenation is very individualized. Thats why its important to discuss your hopes and expectations during the initial facial consultation with your surgeon. In your initial consultation, make sure to discuss and select a treatment option based on your goals and concerns, your anatomy problems and your lifestyle. Make sure that your aesthetic ideals match what your cosmetic surgeon invisions. There is a definite art involved for appropriate filler injections. It is NOT paint by numbers; but rather face sculpturethe key is not the filler; but the artist who is completing the procedure. When injectables are administered by a qualified surgeon, complications are infrequent and usually minor in nature.

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It is wise to search the internet for effects and characteristics of the above listed facial fillers prior to a facial evaluation and treatment planning. Well educated, you will be better prepared to discuss options and choices with your physician artist. n Dr. James E. White is board certified in General Surgery by the American Board of Surgery, in venous disease by the American Board of Phlebology, and in cosmetic surgery by the American Board of Cosmetic Surgery. He is a Fellow of the prestigious American College of Surgeons, a Diplomat of the American Board of Phlebology, and a Fellow of the American Academy of Cosmetic Surgery. Recently voted 2010 Best of the Best in Cosmetic Surgery, his office, Advanced Surgical Concepts, 7446 Shallowford Road, Suite 205 in Hamilton Office Park, offers a variety of cosmetic procedures including laser skin resurfacing, facial fillers, minimal invasive cosmetic surgery and Botox. He may be contacted at 423-648-4011.

WOMAN'S WAY - July 2011

by James E. White, M.D., F.A.C.S.

esthetic surgery of the lips has evolved as the field of cosmetic surgery has evolved, as the study aesthetic finesse. Luscious full lips speak of youth and vitality. The lips thin as people age, and the wet line moves lower in reference to the dentition. In addition, the oral commissures begin to downturn. These thin, flat, and poorly defined lips impart a sense of age. Specific procedures address each of these labial-aging signs. Some of these procedures include augmentation to help restore full, well-defined, and proportional lips that impart a sense of beauty and youth. The lips are the most malleable and animate of all facial features. Many consider them to be the most pleasing feature of the lower third of the face. Many of the techniques used on other areas of the face may not work on the lips because of their 3-dimensional animate nature. With this in mind, many methods are used to augment the lips and to change their animate shape, repose shape, or both. The surgeon must always be aware of how static changes to the lip change the animate aesthetics and function of the lip. Patients occasionally refer to this as kissability. Initial attempts at beautifying the lips probably started with Cleopatra, who colored her lips red. Later, silicone was used to augment the soft tissue of the body

and face, including the lips. Other materials were then developed that could be used for lip augmentation. Some of these materials include collagen, facial fillers, fat, and acellular human matrix, just to name a few. Many new injectable materials used to augment the lips have become available, and many more are to be approved by the US Food and Drug Administration (FDA). Temporary injectable materials are the most common method of lip augmentation and reshaping. The problem with temporary injectable fillers is the fact that they are temporary. The newest advanced lip augmentation procedures involve the placement of a solid silicon implant similar to silicon implants used in breast augmentation procedures. The solid silicon implant can be placed into the upper and lower lips through 3mm incisions in the corner of the mouth. These incision sites heal rapidly and are barely visible to inspection after placement. The silicon implants come in several different sizes for permanent lip enhancement. The old silicon injections, like the ones completed on Ms. Priscilla Presley, caused lip deformity with invasive growth into the lip tissues. Injectable silicon is difficult to remove without major surgical excision. Silicon implants, however, can be easily removed if the lip augmentation look is no longer desired. The silicon implants have a soft natural feel. All lip procedures may be performed in an office surgical suite with local anesthetic (field block, nerve block) and this is, in fact, an ideal way to work on the lips. With general anesthesia, the lips become flaccid and adynamic. The ability for the patient to move the lips during surgery is a great advantage during the sculpture phase. Again, well defined, full lips speak of youth and

Kissability

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vitality. Take care to review before and after photographs of patients treated by your cosmetic surgeon. Make sure that your ideal of aesthetic sense is the same as your surgeon. Beware of lip overfill; big pink slugs and platypus lips do not fit into the category of kissability. n Dr. James E. White is double board certified in General Surgery by the American Board of Surgery and the venous disease American Board of Phlebology. He is a Fellow of the prestigious American College of Surgeons, a Diplomat of the American Board of Phlebology, and a Fellow of the American Academy of Cosmetic Surgery. Recently voted 2010 Best of the Best in Cosmetic Surgery, his office, Advanced Surgical Concepts, 7446 Shallowford Road, Suite 205 in Hamilton Office Park, offers a variety of cosmetic procedures including laser skin resurfacing, facial fillers, minimal invasive cosmetic surgery, Thermage and Botox. He may be contacted at 423-648-4011.

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aricose veins range in severity from small treadlike spider veins to large ropy veins ... cosmetic to medically significant. There are several adverse consequences of untreated varicose veins, and their severity will vary from person to person depending on the circumstances. Many people who dont treat their varicose veins may experience continued symptoms of pain, fatigue and swelling of the legs or ankles. Some varicose veins present without symptoms and just look bad. More advanced medical problems may include hyperpigmentation [stains], lipodermatosclerosis [plastic changes of the skin], venous leg ulcers, spontaneous bleeding, superficial thrombophlebitis, and a potentially life-threatening condition called deep vein thrombosis [DVT]. The varicose veins themselves are not responsible for the major damages to the body. Blood that pools in the varicose veins is depleted of oxygen and nutrients. The veins also do not tolerate high pressure well and begin to allow red blood cells and fluid to leak into the tissues of the leg. This fluid leak causes ankle swelling. The red blood cells in the tissues cause chronic inflammation and the skin becomes dark and discoloredby James E. White, M.D., F.A.C.S.

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WOMAN'S WAY - June 2011

What can happen if I don't treat my varicose veins?

iron stains. The medical term for the dark discoloration is hyperpigmentation. When the skin and the fat under the skin are inflamed for years, the tissues become woody and firm. The medical term for this woody, hard tissue is lipodermatosclerosis. A condition that may occur over time, when there is chronic venous insufficiency, is a venous leg ulcer. The ulcers due to varicose veins are painful and difficult to heal. Sometimes the ulcers cannot be healed until the backward blood flow in the veins is corrected. Another possible consequence of untreated varicose veins is spontaneous bleeding from the varicose veins. As the skin over the veins becomes thin, eventually the vein can be exposed to the outside world and be easily injured by clothing, bedding, etc. The blood loss can be significant and is painless. Superficial thrombophlebitis (ST) is an inflammation of a vein just below the surface of the skin. The cause of inflammation is not an infection. Rather, inflammation is due to decreased blood flow through the vein, damage to the vein and blood clotting. The features of ST include redness to the skin and a firm, tender, warm vein. Localized leg pain and swelling may occur as well. Treatment of ST is directed toward reducing the inflammation. Aspirin or Ibuprofen are the drugs of choice. Compression with graduated support hosiery is important as well. Fortunately, ST is usually a benign and short-term condition. Symptoms generally improve in one to two weeks although the firmness of the vein may persist longer. Deep vein thrombosis (DVT), unlike ST, can be associated with significant and serious medical problems. DVT is often first noticed as a pulling sensation in

the calf of the lower leg, and it can be quite painful. Symptoms also include associated warmth, redness and swelling. The swelling often extends to above the knee. Some patients are at higher risk for developing DVT. These include: Over 60 years of age Recent surgery History of prior DVT Prolonged immobility/paralysis Malignancy Blood Clotting Disorders Obesity Pregnancy and Postpartum Infection When a diagnosis of DVT is made, anticoagulation treatments are often started. Anticoagulation prevents progression of the blood clot, breaks up the clot and prevents the clot from traveling to the lungs. If a clot travels to the lungs it is called a pulmonary embolus and the outcome can be fatal. n Dr. James E. White is double board certified in General Surgery by the American Board of Surgery and the venous disease American Board of Phlebology. He is a Fellow of the prestigious American College of Surgeons, a Diplomat of the American Board of Phlebology, and a Fellow of the American Academy of Cosmetic Surgery. Recently voted 2010 Best of the Best in Cosmetic Surgery, his office, Advanced Surgical Concepts, 7446 Shallowford Road, Suite 205 in Hamilton Office Park, offers a variety of cosmetic procedures including laser skin resurfacing, facial fillers, minimal invasive cosmetic surgery, Thermage and Botox. He may be contacted at 423-648-4011.

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by James E. White, M.D., F.A.C.S. t was just a few years ago that patients unhappy with facial droop had limited choices full facelift. Advances in minimally invasive facial rejuvenation have opened the field of choices for facial lifting. Midface suspension ribbon lift, also referred to as a cheek or midface lift, corrects sagging midface tissues by surgically repositioning them up and to the side. This accomplishes several goals: volume enhancement of the midface region, elimination of hollows in the area, and a gentle smoothing of the tissues just below the eyes. A successful midface suspension can be a key step in achieving the youthful appearance sought after in minimally invasive facial rejuvenation procedures. As we age our mid face degrades, deflates and descends giving that dragged out tired look of 'old age.' The area between the lower eyelids and the mouth is considered the midface. As we age, the effects of gravity, repeated muscle contraction, and lifestyle cause the skin, fat, and muscle in this region to move downwards. When this occurs, the cheeks begin to look saggy or flat, lower eyelids can become puffy or hollow, circles begin to appear under the eyes, and

WOMAN'S WAY - May 2011

the lines between the nose and the corner of the mouth increase in size. Good candidates for mid face suspension ribbon lift are those patients who are starting to see some droopiness of the brow, cheeks, jowls and/or neck and would like to see a lift effect, but do not want the risk, scars, or recovery of a real browlift, facelift, or necklift operation. The ribbon lift procedure can achieve 60-70 percent of what a real invasive surgical procedure can deliver without the need for hospital care or general anesthesia. During a midface suspension procedure, the surgeon makes small incisions in the area above the ear, and in some cases through the mouth. A surgical ribbon implant is then passed through the cheek tissue and secured to the soft tissues above the ear. Similar techniques were tried with suture suspension. The ribbon allows greater fixation than small sutures. In all cases, the surgeon relies upon the implant ribbon to temporarily fixate the suspended cheek in its new position. The ribbon material is slowly absorbed and the tissues created by the body hold the lifted facial tissues fixed in position. This restores cheek volume and establishes more youthful midface contours. The result will be a natural, revitalized appearance that doesnt appear overdone, plastic or pulled. When performed skillfully, a midface ribbon lift can deliver a natural but noticeable improvement. It is frequently performed with other procedures. However, for many younger patients, under 45 years of age,

Ribbon facelift

midface suspension is often a standalone procedure. Good candidates must have realistic expectations and be prepared to follow the postoperative recovery protocol and must be accepting of the risks. Poor candidates include those patients with unrealistic expectations, have uncontrolled medical illnesses that affect wound healing, are grossly overweight (with heavy faces) or are excessively thin, have loose skin. The mid face ribbon suspension may be combined with other, more minor surgical procedures, such as fat transfer, Botox, injectable fillers, fractionated skin resurfacing, deep chemical peel or photofacial intense pulse light treatments. All procedures can be completed using local anesthesia by a cosmetic surgeon as in-office minimally invasive facial rejuvenation. n Dr. James E. White is double board certified in General Surgery by the American Board of Surgery and the venous disease American Board of Phlebology. He is a Fellow of the prestigious American College of Surgeons, a Diplomat of the American Board of Phlebology, and a Fellow of the American Academy of Cosmetic Surgery. Recently voted 2010 Best of the Best in Cosmetic Surgery, his office, Advanced Surgical Concepts, is located at 7446 Shallowford Road, Suite 205 in Hamilton Office Park. Advanced Surgical Concepts offers a variety of cosmetic procedures including laser skin resurfacing, facial fillers, minimal invasive cosmetic surgery, Thermage and Botox. He may be contacted at 423-648-4011.

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by James E. White, M.D., F.A.C.S. ot a week goes by that someone doesn't seek consultation in regard to facial aging with these very words, I want to look fresh, younger but not pulled or plastic. Well, times have changed in regard to facial aesthetics. Gone are the days of the cookie cutter facelifts which often times left patients looking pulled, pinched or wind blown. Newer short-scar mini-lifts, along with procedures to add facial volume and decrease the lines and wrinkles, have revolutionized the art of facial rejuvenation. As we age, most individuals lose elasticity in their skin and develop varying degrees of descent along the jaw line and beneath the chin. The office-based mini face lift is a surgical face lift to address the mid to lower face/neck with minimal surgical exposure as a minimally invasive office procedure. The post operative effect provides a more natural appearance with limited down time when compared to other formal face lift procedures. Most traditional facelifts are performed with general anesthesia and involve multiple weeks of downtime with a long incision beginning at the upper

WOMAN'S WAY - April 2011

Not pulled or plastic

temples and extending behind the hairline on either side of the face to the nape. Due to the length of the formal face lift procedure and the type of anesthesia, there is an increased risk of complications. The S-Lift minimal incision face lift has been performed since the late 1990s. The office based mini face lift not only tightens skin, it is designed to permanently suspend the underlying muscles and fibrous structures of the lower face and upper neck. This suspension of the lower face offers men and women the benefit of a more youthful appearance without the wind blown look of a formal face lift. Key to a natural looking facial rejuvenation is replacement of lost volume. Facial volume can be replaced by fillers or fat transfer. Fat transplant is performed by extracting fat from one area of the body (typically thighs or abdomen) via liposuction and then injecting the filtered fat through a syringe to various areas of the face to increase volume and decrease wrinkles. The fat also has the added benefit of stem cells. As we age, our skin thins and appears more translucent. Sun damage becomes more evident through age spots and a decrease in collagen is pronounced through folds and wrinkles. Laser skin resurfacing is an effective way to correct these issues. The fractionated CO2 laser, heats and vaporizes skin tissue one spot at a time. The heat removes superficial layers of the treated skin while the untouched, surrounding skin aides in the healing process. This healing process stimulates

collagen, elastin and glycosaminoglycans. Ultimately, cell regeneration is induced with production of new skin cells. Neuromodulators like Botox can also be injected to relax facial muscles. It is most beneficial for the treatment of lines caused by overactive muscles of the forehead, cheeks and mouth. This makes it an ideal treatment for frown lines, forehead furrows, and also crows feet. It can also be injected to reverse the downward turn of the angle of the mouth. As with any cosmetic procedure; choose your surgical artist well. The combination of minilifts, volume replacement, neuromodulators and skin resurfacing yield more lasting natural facial rejuvenation without the pulled or plastic look of days gone by. n Dr. James E. White is double board certified in General Surgery by the American Board of Surgery and the venous disease American Board of Phlebology. He is a Fellow of the prestigious American College of Surgeons, a Diplomat of the American Board of Phlebology, and a Fellow of the American Academy of Cosmetic Surgery. Recently voted 2010 Best of the Best in Cosmetic Surgery, his office, Advanced Surgical Concepts is located at 7446 Shallowford Road, Suite 205 in Hamilton Office Park. Advanced Surgical Concepts offers a variety of cosmetic procedures including laser skin resurfacing, facial fillers, minimal invasive cosmetic surgery, Thermage and Botox. He may be contacted at 423-648-4011.

WOMAN'S WAY - March 2011

by James E. White, M.D., F.A.C.S.

rom "Twilight" to "True Blood," vampires were all the rage in 2010. And so are procedures that erase wrinkles from the face. Combine the two trends and you get the vampire facelift. Normal aging causes loss of skin elasticity and volume that encourages the formation of lines, wrinkles and folds. These changes often cause us to appear angry, tired or stressed even if we arent. There is now available an autologous platelet and fibrin processing procedure that uses your own blood to prepare a smooth gel for volume replacement, collagen stimulation and cell renewal. This procedure eliminates facial folds and wrinkles naturally, by using your own blood to stimulate collagen regeneration and volume replacement. Increased skin volume and amazing rejuvenation occurs as new collagen and blood vessels develop, while your own tissues reverse the signs of aging. There is no risk of allergic reaction, little to no bruising, swelling or lumping occurs and long lasting results are clearly visible within a short time period. A popular choice for men and women today who want to defy aging by looking years youngernaturally,... this procedure is todays safest, most effective way to naturally promote cell regeneration. It is considered the next best thing to a facelift without an incision. The system allows for the safe and rapid preparation of an activated platelet rich fibrin matrix (PRFM), in an easy

three step process. A small amount of your own blood is used to prepare the smooth gel that is injected into pre-targeted areas of the face and body. This stimulates new tissue growth and collagen renewal providing skin volume that eliminates lines, wrinkles and folds. Your own new tissues act to reverse the signs of aging. Treatment involves a fast, easy 20 minutes in the comfort of an office setting using local anesthetics. Many men and women get their desired results after only one treatment. Your cosmetic surgeon can personalize a treatment plan for you to optimize your desired results. Cost for the procedure ranges from $800-$1200. The system is FDA cleared and has been safely and effectively used to treat many thousands of patients worldwide. It contains only autologous [your own] active components and there are no risks of allergic reactions. It has been used extensively in cosmetic plastic surgery, orthopedics, maxillofacial surgery and for soft tissue regeneration worldwide.Treatments help to stimulate your bodys own collagen production which in turn provides a gradual increase in volume. One main benefit is that it isnatural.Plateletrich plasma has growth factors and those growth factors stimulate your own body to make collagen. A small amount of your blood is drawn and the platelets and fibrin are separated into a concentrate known as the matrix. This is then injected just below the skin to correct depressions, acne scars, folds and wrinkles. Upon injection, the platelets release growth factors that trigger

Vampire facelift

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cell proliferation thereby increasing volume and naturally rejuvenating the treated areas. Some results are seen right away, but the full effect comes in about three to eight weeks. Results can last up to two years with single injection. The vampire filler won't give one super powers, butit will keep patients looking younger, longer. It is the new eco-green, because it's truly recycling at the basic level. n Dr. James E. White is double board certified in General Surgery by the American Board of Surgery and the venous disease American Board of Phlebology. He is a Fellow of the prestigious American College of Surgeons, a Diplomat of the American Board of Phlebology, and a Fellow of the American Academy of Cosmetic Surgery. Recently voted 2010 Best of the Best in Cosmetic Surgery, his office, Advanced Surgical Concepts is located at 7446 Shallowford Road, Suite 205 in Hamilton Office Park. Advanced Surgical Concepts offers a variety of cosmetic procedures including laser skin resurfacing, facial fillers, minimal invasive cosmetic surgery, Thermage and Botox. To learn more about the Selphyl system (vampire facelift) described above, call 423-648-4011.

health & wellness

A
by James E. White, M.D., F.A.C.S. s we age, the underlying collagen and elastic connective tissues begin to break down and wrinkles emerge. We also tend to lose some subcutaneous fat on our faces. This brings about a haggard, hollow, or even skeletal look. Fat grafting is a natural approach to restoring a youthful look to the face that does not involve removal of skin, stretching the skin, or the risk of an unnatural look that can result from a face lift. Fat grafting can be combined with a face lift, if volume is what one needs. Fat transfer also called facial fat rejuvenation is the process of taking small amounts of fat from one part of the body and reimplanting it elsewhere, where it is needed. This fat can be implanted to the lips, the nasolabial folds (the folds from the corners of the mouth, nose), the under-eye areas, the cheeks and other parts of the face and body. It is minimally invasive and can be completed in an office setting to help correct problems such as volume loss, acne scars and restore a youthful look to an aging face. As an injectable filler, fat is almost perfect. It is soft and feels natural, it does not cause immune problems,

12

WOMAN'S WAY - February 2011

and most people have fat to spare! The fat is harvested from some other spot on your body, such as you abdomen, and can be a by-product, if you will, of liposuction reduction of that area. The main downside to fat grafting is that the body tends to absorb the transferred fat at least to some degree. The amount of fat that is implanted and then absorbed by the body varies. Some older studies have found that almost all the fat is absorbed, but there has been a lot of recent improvements in techniques for harvesting, treating and injecting the fat. Many cosmetic surgeons are reporting very good, lasting results with the newer techniques. A lot depends on factors including how the fat was removed, how it was concentrated and treated, how much was injected, where it was injected. To be a good candidate for facial fat grafting, one has to be in good health, not have any active diseases or pre-existing medical conditions, and one must have realistic expectations of the outcome. One may not be a good candidate for fat grafting if there is a history of poor wound healing or if the overall health is poor. Fat grafting can be done on almost all areas of the face and body. However, the most common treatment sites are the areas under the eyes, the tear troughs under the eyes, the temples, the cheeks, the chin, the lips, the jaw line, the forehead, and the glabella (the area just above the nose in between the brows). Fat grafting has been used on the breast, buttocks and hips and the sternum. The site being treated must have good blood circulation and enough capillaries and larger blood vessels so that the injected fat cells are nourished and can form their

Fat transfer

own blood supply. This is a key factor in getting the best and longest lasting results. Surgeons are continuing to discover new methods of aesthetic improvements through fat grafting. Although fat grafting and other types of grafting are still not perfect, they have certainly come a long way over the last few years. n Dr. James E. White is double board certified in General Surgery by the American Board of Surgery and the venous disease American Board of Phlebology. He is a Fellow of the prestigious American College of Surgeons, a Diplomat of the American Board of Phlebology, and a Fellow of the American Academy of Cosmetic Surgery. Recently voted 2010 Best of the Best in Cosmetic Surgery, his office, Advanced Surgical Concepts is located at 7446 Shallowford Road, Suite 205 in Hamilton Office Park. Advanced Surgical Concepts offers a variety of cosmetic procedures including laser skin resurfacing, facial fillers, minimal invasive cosmetic surgery, Thermage and Botox. He may be reached at 423-648-4011.

WOMAN'S WAY - January 2011

by James E. White, M.D., F.A.C.S.

Cosmetic surgery homework

perform cosmetic surgery. While board certification by the American Board of Plastic Surgery may evidence a physician competent in plastic surgery, it does not necessarily evidence competency in cosmetic surgery nor does it demonstrate more cosmetic surgery education, training or experience than that of a boardcertified surgical specialist with post residency training in cosmetic procedures. A recent article published in the Plastic Surgery Journals reported that 51 percent of plastic surgery residents felt that they did not receive sufficient training in cosmetic surgery procedures during their plastic surgery residency. The cosmetic surgery field is rapidly changing. Most non-invasive rejuvenation procedures have only been around for the last seven years. If your plastic surgeon completed his/her plastic surgery residency more than seven years ago chances are he/she learned the cosmetic procedure techniques just like other providers at a post residency training course. Choose your cosmetic surgeon as you would choose any other healthcare provider. Consistently, it is the American Medical Associations policy that individual character, training, competence, experience and judgment be the criteria for granting privileges and that physicians representing several specialties can and should be permitted to perform the same procedures if they meet the criteria. Surgeons develop their cosmetic surgical skills through post residency training and experience. The point is that a cosmetic surgeons skill and ability will depend on the surgeons cosmetic surgery training and experience, not on core board-certification. As for how you should choose a cosmetic surgeon or cosmetic surgical center...you should do

beauty & fashion

the research locally and online. You can perform a standard internet search with the name of the doctor or on the procedure that you would like to receive more information. What do you see online? Negative or positive feedback on reviews? Ask those in the waiting room or others that you know if they have any feedback. If you are visiting a surgical center, where multiple doctors work, be sure to get the name of THE surgeon who will be performing your procedure. Make sure that your surgeon has a good reputation, a strong background in the surgical field, and above ALL that he/she produces good results. Training is important; but skill, judgment and artistic detail are evidenced by experience, not just board certification. n Dr. James E. White is double board certified in General Surgery by the American Board of Surgery and the venous disease American Board of Phlebology. He is a Fellow of the prestigious American College of Surgeons, a Diplomat of the American Board of Phlebology, and a Fellow of the American Academy of Cosmetic Surgery. Recently voted 2010 Best of the Best in Cosmetic Surgery, his office, Advanced Surgical Concepts is located at 7446 Shallowford Road, Suite 205 in Hamilton Office Park. Advanced Surgical Concepts offers a variety of cosmetic procedures including laser skin resurfacing, facial fillers, minimal invasive cosmetic surgery, Thermage and Botox. He may be reached at 423-648-4011.

re you thinking about undergoing cosmetic surgery? Do your homework! Cosmetic surgery is a subspecialty that uniquely restricts itself to the enhancement of appearance through surgical and medical techniques. It is specifically concerned with maintaining normal appearance, restoring it, or enhancing it toward some aesthetic ideal. Cosmetic Surgery is a multi-disciplinary and comprehensive approach directed to all areas of the head, neck and body. Cosmetic surgery is practiced by surgeons from a variety of disciplines including board-certified dermatologists, general surgeons, oral and maxillofacial surgeons, ophthalmologists, otolaryngologists, plastic surgeons and physicians from other fields. All of these disciplines have contributed to the vital growth of cosmetic surgery and its current practice. Unlike cosmetic surgery, plastic surgery deals with the repair, reconstruction or replacement of physical defects of form, defects from cancer surgery, trauma and disease processes. Cosmetic surgery deals with tissue arrangements by enhancement toward an aesthetic goal. When considering cosmetic surgery, people are almost universally unaware that there is a difference between cosmetic surgery and plastic surgery. For this reason, they may be easily misled to believe board certification in plastic surgery evidences a physicians competence to

WOMAN'S WAY - January 2009

Scar technology
by James E. White, M.D., F.A.C.S.

beauty & bridal

eight weeks after an incision has been made. More invasive laser treatments can improve and atten the appearance of deeply ingrained scars. Coloration changes with red to purple pigment changes at incision sites are best treated with intense pulse light (IPL) photodynamic therapy. IPL affects color changes in the skin; causing dark skin pigments to fade to a more normal coloration. White scars are devoid of pigment cells and usually will not respond to therapy. Surgical tattoos can be helpful to camouage the white scars in cosmetically sensitive areas. If all else fails, consider makeup concealers for problem scars. Some patient are using temporary tattoos to cover scar imperfections while on vacation with skin areas exposed at the beach. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery, is a Fellow of the American College of Surgeons and is a Diplomat of the American Board of Phlebology. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. Located at 7446 Shallowford Road, Suite 205 in Hamilton Ofce Park, he may be contacted at 423- 648-4011.

15

s a natural part of the healing process, a scar forms as a results of injury and new collagen bers which reconnect damaged skin and create a seam or scar. The most common causes for scars include surgical incisions, traumatic injuries and inammatory scars. Your options for getting rid of that scar may depend on the type of scar that you have. Hairline scars are thin, at and easy to fade or hide. Good surgeons strive to place surgical scars in less conspicuous locations following tension lines of the body. Careful attention to detail allows for better nal cosmetic results. Unfortunately, we have no control over traumatic scars which seem to occur in areas of skin exposed without fabric protective covers. Atrophic or depressed scars have a sunken or pitted appearance. Acne is a frequent culprit. Hypertrophy scars are rm, raised accumulations of tissue that develop from an overabundance of collagen production and sometimes grow larger that the original wound or traumatic injury site. These scars are unsightly and can also be painful. Keloid scars are the largest hypertrophic scars, often time looking more like tumors than scars. African-American and patients of Mediterranean heritage

are very susceptible to keloid scarring. The key to minimal scarring is prevention. For acne patients, a qualied physician can put together an effective skincare regimen with specic products that will help to prevent acne scarring. Blue light therapy or photodynamic therapy is one of the current cutting edge technologic procedures for acne. If you are prone to poor healing with hyper tropic or keloid scars, protective dressings, suture techniques, compression therapy and steroid injections may reduce the risks. Advanced keloid scars may respond to radiation therapy in early stages of wound healing. Of key importance, ask your surgeon about his or her suturing techniques and inform the surgeon of any personal or family history of poor wound healing problems. Avoid surgeons who close wounds with wide suture techniques which often leave the Frankenstein railroad scars." Look for surgeons who use layer closure techniques with fast absorbing sutures supported by skin bridges or buttery bandages. Multiple techniques can decrease scarring after the initial skin injury. During the healing phase, simple topical treatments (ScarGuard, KeloCote, Mederma) and steroid injections can help to minimize the unsightliness of a scar. Scarabrasion by using a soft bristle babys toothbrush along with fractionated laser treatments to the healing incision is helpful in the rst six to

health & wellness

by James E. White, M.D., F.A.C.S.

12

WOMAN'S WAY - December 2008

Varicose veins
usual answer for a mechanical problem is a mechanical therapy. Premiere vein centers use endovenous laser techniques to permanently seal faulty varicose veins in a conservative non-surgical method. Advanced varicose veins may lead to vein inammation [phlebitis], deep vein thrombosis [blood clots] and non-healing ulcers and sores of the lower extremities. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery, is a Fellow of the American College of Surgeons and is a Diplomat of the American Board of Phlebology. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. Located at 7446 Shallowford Road, Suite 205 in Hamilton Ofce Park, he may be contacted at 423- 648-4011.

aricose veins, those unsightly twisting, bulging ropelike cords on the legs, anywhere from the groin to ankle affect an estimated 40 percent of women and 25 percent of men of all ages. The problem veins generally appear from age 20 and forward. Factors leading to varicose veins include heredity, gender, pregnancy, age and other factors. Some factors may speed up the development of this disease and make the veins worse. The major factors include: pregnancy, prolonged standing in one place, obesity, hormone levels, and physical trauma from previous episodes of deep vein thrombosis. Varicose veins of the rectum are called hemorrhoids and varicose veins of the esophagus are called esophageal varicies. While many people have heard of varicose veins of the legs, very few truly understand their underlying cause, and the potential they have for developing into a serious medical issues. Veins return blood back to the heart to be recirculated. To return this blood to the heart, the leg veins must work against gravity to lift the blood back to the heart. This gravity effect is multiplied when standing. Small, one-way valves in the veins open to allow blood to ow upward, towards the heart, and then close to prevent it from owing backwards. Muscle pumps in the lower limbs push the blood upward with each muscle contraction. Obstacles in the way of blood return to the heart [such as pregnancy or obesity] also decrease the ability of the veins to return the blood back to the heart efciently.

In addition to the visual appearance, many patients may experience pain (an aching or cramping feeling), heaviness/tiredness, burning or tingling sensations, leg swelling/throbbing as well as tender areas around the veins themselves. Varicose veins occur when the valves in supercial leg veins malfunction or cannot work efciently. When this occurs, the valve may be unable to close, allowing blood that should be moving towards the heart to ow backward (called venous reux). The vein blood becomes stagnate, backs up and pressure builds. Blood collects in your lower veins causing them to enlarge and become varicose. The veins are very thin walled and cannot tolerate the increased pressure; they enlarge in relationship to the added stress. The pressure maybe so great that uid can leak from the faulty veins causing leg swelling leading to dermatitis and skin ulcerations. Varicose veins have been shown to be the number one cause for restless leg syndrome. Conservative measures [like compression hose] do not treat the underlying cause of the disease process. Compression therapy helps adjust the supercial vein pressure to cause the vein blood ow to take other veins deeper in the limb. Without correction of the mechanical problem, varicose veins will usually enlarge and worsen over time. Legs and feet may begin to swell and sensations of pain, heaviness, burning or tenderness may occur. Twisted ropey varicose veins are related to mechanical problems and the

WOMAN'S WAY - November 2008

Non-surgical eye lift

by James E. White, M.D., F.A.C.S.

beauty & fashion

ment session is all that is needed. The tightening effect should last from two to four years according to skin types until the current aging process catches up and starts skin degradation again. Most patients experience a brief, deep heating sensation as the RF energy is delivered to the skin and underlying tissue. Normally, the complete procedure can be performed in just one session lasting from 20 minutes to two hours, depending on the treatment area and the desired result. General anesthesia is not required, but light sedatives are recommended prior to treatment. Most patients experience only minor redness, which subsides within an hour or so after the procedure. Over time, new and remodeled collagen is produced to further tighten skin, resulting in healthier, smoother skin and a more youthful appearance ... that glow from the fountain of youth. The Thermage procedure is available only in the ofces of qualied physicians who specialize in surgical and non-surgical cosmetic procedures. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery, is a Fellow of the American College of Surgeons and is a Diplomat of the American Board of Phelebology. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. Located at 7446 Shallowford Road, Suite 205 in Hamilton Ofce Park, he may be contacted at 423- 648-4011.

21

ne of the rst places that our face can show aging is around the eyes the windows to the soul. Skin and soft tissues around the eyes start to loosen and sag in the mid 30s with loose, lax skin, hoods and wrinkles. Treatments for skin laxity and descent included blephroplasty, facial lifts and Thermage which effectively tighten and lift the skin. Blephroplasty is a surgical technique used to remove excess lax skin from the upper and lower eyelids. This surgical procedure is offered to the more severe cases of skin laxity around the eyes. The Thermage Non-Surgical System lifts and tightens sagging skin without surgery by radiofrequency heating of the skin. As we age, our skin loses elasticity and strength due to loss of collagen. This supporting material of the skin [collagen] deteriorates with time and age. If the body is tricked into replacing the collagen, the skin becomes thicker and rmer effecting a more youthful appearance. Most commonly used for face, and eyelid skin laxity, the Thermage procedure may also be used to tighten

loose and sagging skin almost anywhere on the body. The procedure employs a patented radiofrequency [RF] similar to microwave energy to tighten and gently lift skin to smooth out wrinkles and renew skin contours. The sophisticated treatment tip delivers controlled amounts of RF energy which causes our deteriorated collagen to contract and be replaced due to simple heat denaturation of the protein. With each touch to the skin, the RF device uniformly heats a volume of collagen in the deeper layers of the skin and its underlying tissue while simultaneously helping to protect the outer layer of the skin from heat with cooling. The technology is so precise, the outer skin is cooled while the deeper skin tissue is heated. This deep uniform heating action causes deep structures in the skin to immediately tighten. Without damaging the surface skin, the radiofrequency energy is absorbed by the deepest dermal layer of skin tissue where it tightens existing collagen and triggers new collagen production. Unlike lasers, the RF procedure can be performed on patients of all skin types. A single treat-

beauty & fashion

by James E. White, M.D., F.A.C.S. Actinic keratoses (AKs) are rough, scaly tan brown patches on the skin, caused by excessive exposure to the sun, that can sometimes progress into dangerous skin cancers. More than 10 million Americans live with these skin lesions thinking that they represent age spots, and far too many people ignore them. Unfortunately, leaving AKs untreated can have serious consequences. Doctors etimate that 40% ofskin cancers [squamous cell carcinomas, the second leading cause of skin cancerdeaths in the United States] begin as AKs. For this reason, major medical groups- The American Cancer Society, The Skin Cancer Foundation, and the American Academy of Dermatology all recommend that people with AKs seek review and treatment options for them immediately. AKs are very common on sun exposed parts of the face, scalp, ears, chest, back and extremities. They present as rough scaly patches of tan to brown skin. Sometimes these patches can become larger and thicker called hyperkeratotic. These enlarged lesions may then progress to changed to frank squamous cell carcinomas. Patients may notice increased redness, tenderness, itching, and burning associated with the thickened rough skin. However, these symptoms can be the same for either AKs or squamous cell carcinomas. This is what makes distinguishing between the two so difcult without a simple skin biopsy. Left untreated, squamous cell carcinomasmay become larger, go deeper into the skin, and

00

WOMAN'S WAY - October 2008

Sun spots: Actinic Keratosis?

eventually spread to other parts of the body by the lymph nodes. This results in thousands of skin cancer deaths each year, many of which could be prevented with appropriate surveillance and early intervention. It is impossible to predict if an AK will evolve into a squamous cell carcinoma, or at which point it will happen. Many doctors believe that AKs and squamous cell carcinomas are really the same condition at different stages of a continuing process. This process begins with minor cell damage and, over time, ultimately results in the cell becoming cancerous. These doctors believe that AKs occur in the early stages of the process; squamous cell carcinomas occur in the nal stage. One thing, however, is certain: a signicant percentage of AKs develop into squamous cell carcinomas. Estimates range from 10% to as high as 20% over a 10-year period of patient with known actinic keratosis. Long-term exposure to the sun is the single most signicant cause of AKs, so the best defense against them is a comprehensive sun protection program. This includes wearing protective clothing and a wide-brimmed hat, avoiding the sun at midday when ultraviolet rays are strongest, staying in the shade as much as possible, andwearing a broad-spectrum sunscreen with a sun protection factor (SPF) of at least 30. Unfortunately many of us already have sun damaged skin and a more aggressive approach is needed. Surgical excision, freezing and electrodessication have been the main tools to deal with AKs. Advanced technology is now available with photodynamic therapy. Levulanic Photodynamic Therapy uses photochemical methods to target minimally to moderately thick Grade 1 or 2 AKs (AKs that have not yet become enlarged and thick). This therapy is unique because it uses light activated drug therapy to destroy AKs in their early stages. The 2-step process consists of treatment to the affected skin with a weak acid solution which is chemically altered by exposure to certain wavelengths of light. When levulanic acid is applied to Grade 1 or 2 AKs, the solution is absorbed by the AK cells where it is converted to a chemical that makes the cells extremely sensitive to light. Topical Solution is applied to the AKs with incubation for the recommended time in order to allow the solution to penetrate the target cells. Target AKs are porous and absorb more of the levulanic acid than does normal skin cells. After an incubation period, the painted skin is then treated with blue light with wavelengths in the 400-450 nm, which is the second and the nal step in the treatment. The levulanic acid is changed to a toxic substance which kills the abnormal cells in which the acid was concentrated during the incubation period with gentle sparing of the normal skin. Over a few days, these abnormal cells die, crust over and slough off with new skin as replacement. The most common side effects include scaling/crusting, hypo/hyper-pigmentation, itching, stinging, and/or burning, erythema and swelling. Photodynamic therapy has proven very effective for thin early actinic kerotosis skin lesions. The treatment has been proven to reverse the signs of early skin cancers. Medicare as well as most insurance agencies will pay for this valuable therapy. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery, is a Fellow of the American College of Surgeons and is a Diplomat of the American Board of Phelebology. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. He is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park, and may be contacted at 423648-4011.

Sun spots: Actinic Keratosis?

by James E. White, M.D., F.A.C.S.

health & wellness

allow the solution to penetrate the target cells. Target AKs are porous and absorb more of the levulanic acid than does normal skin cells. After an incubation period, the painted skin is then treated with blue light with wavelengths in the 400-450 nm, which is the second and the nal step in the treatment. The levulanic acid is changed to a toxic substance which kills the abnormal cells in which the acid was concentrated during the incubation period with gentle sparing of the normal skin. Over a few days, these abnormal cells die, crust over and slough off with new skin as replacement. The most common side effects include scaling/crusting, hypo/hyper-pigmentation, itching, stinging, and/or burning, erythema and swelling. Photodynamic therapy has proven very effective for thin early actinic kerotosis skin lesions. Treatment has proved to reverse the signs of early skin cancers. Medicare and most insurances pay for this therapy. n Dr. James E. White is board certied in General Surgery
by the American Board of Surgery, is a Fellow of the American College of Surgeons and is a Diplomat of the American Board of Phelebology. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. Located at 7446 Shallowford Road, Suite 205 in Hamilton Ofce Park, he may be contacted at 423- 648-4011.

WOMAN'S WAY - October 2008

25

ctinic keratoses (AKs) are rough, scaly tan brown patches on the skin, caused by excessive exposure to the sun, that can sometimes progress into dangerous skin cancers. More than 10 million Americans live with these skin lesions thinking that they represent age spots, and far too many people ignore them. Unfortunately, leaving AKs untreated can have serious consequences. Doctors estimate that 40 percent of skin cancers [squamous cell carcinomas, the second leading cause of skin cancer deaths in the United States] begin as AKs. For this reason, major medical groups The American Cancer Society, The Skin Cancer Foundation, and the American Academy of Dermatology all recommend that people with AKs seek review and treatment options for them immediately. AKs are very common on sun exposed parts of the face, scalp, ears, chest, back and extremities. They present as rough scaly patches of tan to brown skin. Sometimes these patches can become larger and thicker called hyperkeratotic. These enlarged lesions may then progress to changed to frank squamous cell carcinomas. Patients may notice increased redness, tenderness, itching, and burning associated with the thickened rough skin. However, these symptoms can be the same for either AKs or squamous cell carcinomas. This is what makes distinguishing between the two so difcult without a simple skin biopsy. Left untreated, squamous cell carcinomas may become larger, go deeper into the skin, and eventually spread to other parts of the body by the lymph nodes. This results in thousands of skin cancer deaths each year, many of which could be prevented with appropriate surveillance and early intervention. It is impossible to predict if an AK will evolve into a squamous cell carcinoma, or at which point it will happen. Many doctors believe that AKs and squamous

cell carcinomas are really the same condition at different stages of a continuing process. This process begins with minor cell damage and, over time, ultimately results in the cell becoming cancerous. These doctors believe that AKs occur in the early stages of the process; squamous cell carcinomas occur in the nal stage. One thing, however, is certain: a signicant percentage of AKs develop into squamous cell carcinomas. Estimates range from 10 percent to as high as 20 percent over a 10-year period of patients with known actinic keratosis. Long-term exposure to the sun is the single most signicant cause of AKs, so the best defense against them is a comprehensive sun protection program. This includes wearing protective clothing and a wide-brimmed hat, avoiding the sun at midday when ultraviolet rays are strongest, staying in the shade as much as possible, and wearing a broad-spectrum sunscreen with a sun protection factor (SPF) of at least 30. Unfortunately many of us already have sun damaged skin and a more aggressive approach is needed. Surgical excision, freezing and electrodessication have been the main tools to deal with AKs. Advanced technology is now available with photodynamic therapy. Levulanic Photodynamic Therapy uses photochemical methods to target minimally to moderately thick Grade 1 or 2 AKs (AKs that have not yet become enlarged and thick). This therapy is unique because it uses light activated drug therapy to destroy AKs in their early stages. The 2-step process consists of treatment to the affected skin with a weak acid solution which is chemically altered by exposure to certain wavelengths of light. When levulanic acid is applied to Grade 1 or 2 AKs, the solution is absorbed by the AK cells where it is converted to a chemical that makes the cells extremely sensitive to light. Topical Solution is applied to the AKs with incubation for the recommended time in order to

beauty & fashion

by James E. White, M.D., F.A.C.S.

10

WOMAN'S WAY - September 2008

Spider veins
therapy solutions have been around since the turn of the century. Saline strong salt solutions were used until more advanced sclerosant medications have yielded better results. Small, ne spider veins or telangiectic matts can be addressed with topical lasers or intense pulsed light (IPL). Laser therapy for spider veins is mainly directed at post sclerotherapy clean-up to address veins that are so small a needle can not be placed into the vessel for solution injection. IPL uses intense light in the laser range to safely penetrate the outer surface of the skin. Varicose veins and spider veins have different coloration than the surrounding skin. Red and blue colors absorb the energy from the laser light, causing the vein walls to be super heated. The heat causes the veins to collapse and with compression stick together. Physician review and ultrasound mapping are primary to determine the best approach for the elimination of unsightly spider veins. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery, is a Fellow of the American College of Surgeons and is a Diplomat of the American Board of Phelebology. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. He is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park, and may be contacted at 423648-4011.

uring the height of summer, many of us put on short and bathing suits, eager to expose our lower limbs to the light of day that we have longed for all winter. But for the estimated 80 million adults in the Untied States who suffer from spider and varicose veins, summer may be a time to draw attention away from the legs. Spider veins, also known as telangiectasia, or broken capillaries, form when groups of blood vessels close to the surface of the skin dilate and break. As a result, ne-lined networks of red, blue or purple veins each barely more than the width of a hair appear on the thighs, calves and ankles. The veins may form patterns resembling a sunburst, a spider web, or a tree with branches, but can also emerge as short, unconnected lines. Although physicians don't know exactly what causes spider veins, they do know some risk factors for developing them. Spider veins tend to run in families. If your mother or sister has them, you likely will too. Estrogen also may play a role (by relaxing the vein walls), which could explain why women are more likely to get

spider veins than men. The upsurge of hormones at puberty, birth control pills, pregnancy and hormone replacement therapy all have been connected to the development of spider veins. Age also makes one ripe for the condition. And an injury, such as being hit in the leg with a softball, increases the chance of developing spider veins later in that same area even if that injury occurs early in life. Spider veins can be treated and eliminated with two major forms of therapy: sclerotherapy and surface laser light treatments. Before treatment begins, a plan of attack must be formulated. First a physical examination and ultrasound examination should be completed to determine the source of the spider veins. Often time patients have sclerotherapy or laser procedures completed with some results and decrease of the spider veins, just to have the veins reappear in a few months. In these cases, the source for the vein pressure wells from below the skin surface in a web of veins called reticular veins. If the larger reticular veins are not dealt with, the surface spider veins will never go away. Larger reticular veins and spider veins can be closed using ultrasound guided foam sclerotherapy. A foamy sclerosant solution is injected directly into the larger reticular veins and spider veins. Ultrasound guidance is used for the deeper veins. The foam sclerotherapy solution causes a chemical burn to the small veins. The veins collapse and with compression stick together. The vein walls heal together causing the vein to no longer act as a vein. The body absorbs the tissue over a few months. Sclero-

beauty & fashion

by James E. White, M.D., F.A.C.S.

22

WOMAN'S WAY - August 2008

Neck liposuction
suction removal easier. The unwanted fat is removed with a high suction vacuum, leaving the skin, muscles, nerves and blood vessels intact. The high level energy delivered by the laser ber or by ultrasound can also be used to heat the undersurface of the skin thus leading to skin retraction and skin tightening. The face and neck are usually the rst features we notice when we meet someone new, so improvements in this area can create a dramatic change. A rm, trim neck gives the face a more youthful look. Sometimes just having this neck liposuction done provides an incentive to make healthier lifestyle choices and maintain tness in the rest of the body. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. He is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park, and may be contacted at 423-648-4011.

s we age, certain areas of the body can accumulate fat that is hard to lose, in spite of a healthy diet and vigorous exercise. The neck is one such area. Fat deposits in the neck can detract from the appearance of the entire body, making a younger person seem older, or a t person seem out of shape. Liposuction can give this area a new streamlined contour, enhancing the effect of facial features and improving the facial prole. Patients who have been self-conscious about their bulging necklines often feel more comfortable wearing a range of clothing and jewelry styles after liposuction. Neck liposuction produces consistently good results and has a particularly high satisfaction rate.

During the initial consultation, your surgeon will talk with you about the changes you would like to make in your appearance. He should explain the different options available, the procedure itself, its risks and limitations and costs. You should have a physical examination to evaluate your overall weight, your skin and muscle tone and the pattern of distribution of fat deposits. Be sure to ask all the questions you have about the procedure, and ask to see photos of the doctors recent patients, before and after treatment. Learning everything you can about your options, risks and benets is the key to making an informed decision. Before surgery, the surgeon will mark the precise areas of the body where the fat is to be removed. Before and after photographs should be taken. An intravenous (IV) line will be inserted in a vein in your arm to make sure the uid level in your body stays within healthy limits throughout the procedure. Neck liposuction is very safe and can be completed in an ofce setting surgical suite. You may be given sedatives for relaxation in addition to numbing medications for local anesthesia. During the procedure, the surgeon makes tiny incisions (1-2mm in diameter) in the skin, typically in the crease just under the chin or behind the ear lobes and low in the neck. A thin tube called a cannula is inserted into the fatty area. The cannula is used to break up the fat deposits and sculpt the area to the desired proportions. The newest liposuction techniques involve the placement of a laser ber or an ultrasound probe through an open ended cannula. Laser energy or high frequency ultrasound energy is delivered directly to the fatty tissues. This focused high level energy causes the fat to be emulsied making

beauty & fashion

by James E. White, M.D., F.A.C.S.

30

WOMANS WAY - June/July 2008

Face the music

and face do not require sutures. Not closing incisions with sutures and allowing open drainage of the blood-tinged anesthetic solution minimizes postoperative bruising and edema. Absorptive pads are applied to absorb the drainage and are held in place by an elastic compression garment. An elastic compression garment is worn after liposuction of face and neck during the rst 18 to 36 hours after surgery. As soon as the drainage has ceased, a compression garment is no longer necessary. In the old days of liposuction, surgeons required that patients wear a compression garment for two to six weeks, but there is no evidence that this prolonged compression provides any benet. Tumescent liposuction is the safest and usually the most effective technique for removing fat from the chin, cheeks and jowls. Liposuction involves fewer complications, fewer scars, avoids the dangers of general anesthesia, has a more rapid recovery, lowers cost, and typically gives a more natural appearance when compared to a formal facelift. n

umescent liposuction of the face and neck are less complex surgical procedures completed in the ofce to remove unwanted fat deposits. The phrase liposuction of the face and neck is somewhat misleading. To be more specific, liposuction in this general area involves the submental (below the jaw) chin, the jowls and a small area of the cheeks. Women who have local deposits of subcutaneous fat in the face and neck and who have excessively wrinkled skin will often get better results from liposuction combined with either a laser resurfacing or a chemical peel, than they would from a facelift. Younger women who have good skin elasticity, liposuction alone can also produce dramatic improvement and is a much simpler and safer procedure than a facelift. Men often choose tumescent liposuction over a facelift because the tell-tail scars and the surgical-look of a facelift are difcult to hide with short hair and are not acceptable for a man. Not all patients are good candidates for liposuction of the face and neck. For some patients a mid-face lift would be

the preferred procedure according to the goals for facial rejuvenation. Short scar mid facelift may be pre- ferred by a woman who has large folds of skin on the neck with little subcutaneous fat. Submental chin includes the area below the margin of the jaw, and extends onto the front of the neck. Regardless of ones age, an inherited localized collection of excess fat beneath the chin makes one look chubby, older and less athletic. Liposuction is usually the simplest, safest and least expensive way to treat this cosmetic problem. Jowls represent a small focal accumulation of fat on the lower cheek overlying the jaw bone. Prominent jowls make a person look old and are a cosmetic concern for both women and men. Cheeks with too much subcutaneous fat can make a person appear chubby. These types of fat deposits are usually the result of an inherited tendency that is resistant to exercise and diet. Tumescent liposuction using very small cannulas (less than 1.5 mm in diameter) can correct this cosmetic problem totally by local anesthesia and with virtually no scars. Liposuction does not eliminate facial wrinkles, but there are modern cosmetic facial resurfacing techniques that do. Facial wrinkles, blotchy pigmentation and acne scars can all be treated by any one of several techniques, including laser resurfacing, chemical peel, dermabrasion or a combination of these techniques. A combination of liposuction plus wrinkle removal can often provide a better overall cosmetic improvement with less down time than a formal facelift. The tiny incisions used for liposuction of the neck

Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. He is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park, and may be contacted at 423-648-4011.

beauty & fashion

by James E. White, M.D., F.A.C.S.

18

WOMANS WAY - May 2008

Scratch the surface

that are absorbed by water and certain substances in the skin called chromophores. The light is changed into heat energy, and the heat then vaporizes thin sections of skin, layer by layer. As the wounded area heals, new skin grows to replace the damaged skin that was removed during the laser treatment. The CO2 (carbon dioxide) laser is the most common type of laser used for resurfacing. Fractionated lasers are also used frequently and are growing in popularity because they do a similar job, but penetrate less deeply and therefore heal more quickly. Laser resurfacing is usually very precise and causes little damage to the surrounding skin and tissue. It is done most often on the face, but it may be done on skin in other areas of the body. Laser resurfacing is usually done in a doctors ofce. The time needed for healing and recovery after laser resurfacing varies according to the size and depth of the treated area. Chemical peeling is completed by applying a chemical solution to the skin. Mild scarring and certain types of acne may be treated. The procedure enables new, regenerated skin to appear, improving the appearance of the condition. Chemical peels are generally recommended for discoloration caused by acne, not deep pitted scars. Commonly used chemical peels are glycolic and lactic acid, which are also available for home use. Subcision (undermining), needling with dermabrasion are used for depressed scars, pitted scarring and ice pick type scars. During a subcision session, a small needle is used to break up the scar tissue underneath the depression. Subcision along with needle rolling are highly effective methods in the treatment of depressed scars, but usually require multiple sessions depending on the number and depth of the scars. These sessions are normally spaced four weeks apart, and require ve to seven days downtime after the procedure. Skin manipulation techniques have been used by physicians for decades. When used correctly, the techniques fool the skin to insight repair without scarring, pigment changes or signicant down time. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. He is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park, and may be contacted at 423-648-4011.

kin that is smooth and supple with a warm glow is a sure sign of youth. As we age, our skin is marked with reminders of our past experiences. The canvas of skin tells a tale of our sun exposure, wrinkles, superficial scars caused by acne, surgery or trauma. The etched skin surface is then painted by color (pigment) changes or defects in the skin, such as liver spots or coffee spots and tattoos. Stressed by smoking and environmental chemicals, all combined, our skin shows the signs of aging. Skin repair techniques have been around for centuries: chemical peels were very popular in the early part of the 20th century, but with a price: scarring and pigment changes. Now safer high tech laser resurfacing techniques result in consistent skin resurfacing, also with a price: the cost of technology. Each technique, from chemical peels to laser resurfacing, have similar properties. They cause controlled damage to the skin, causing the underlying skin to rapidly reproduce and slough off the old damaged skin, resulting in new, more youthful skin in place of the timeworn and etched skin. Laser resurfacing uses heat induced by laser light to destroy and remove (vaporize) the upper layers of the skin. This causes new skin to grow. It is typically used to remove or improve the appearance of wrinkles, shallow scars (from acne, surgery or trauma), tattoos and other skin defects. The laser sends out brief pulses of high-energy light

beauty & fashion

10 by James E. White, M.D., F.A.C.S.

WOMANS WAY - April 2008

Treatment of scars and wrinkles

L
aser resurfacing uses heat induced by laser light to destroy and remove (vaporize) the upper layers of the skin. This causes new skin to grow. It is typically used to remove or improve the appearance of wrinkles shallow scars (from acne, surgery or trauma) and other skin defects. The laser sends out brief pulses of high-energy light that are absorbed by water and certain substances in the skin called chromophores. The light is changed into heat energy, and the heat then vaporizes thin sections of skin, layer by layer. As the wounded area heals, new skin grows to replace the damaged skin that was removed during the laser treatment. The CO2 (carbon dioxide) laser is the most common type of laser used for resurfacing. Fractionated lasers are also used frequently and are growing in popularity because they do a similar job, but penetrate less deeply and therefore heal more quickly with little or no down time. Laser resurfacing is usually very precise and causes little damage to the surrounding skin and tissue. It is done most often on the face, but it may be done on skin in other areas of the body like the chest, back and hands. The areas to be treated by laser resurfacing are cleaned and marked with a pen. A nerve block with a local anesthetic is usually used to numb the area before treatment. You may also be given a sedative or anti-anxiety medication. If your entire face is going to be treated, you may need stronger anesthesia (in some cases, general anesthesia), pain relievers or sedation. You may be given goggles to wear to prevent eye damage by the laser. The laser is passed over the skin, sending out pulses. Each pulse lasts less than a millisecond. Between passes with the laser, the skin may be cooled. The number of passes required depends on how large the area is and what type of skin is being treated as well as the type laser used for the treatment. Thin skin around the eyes, for instance, requires very few passes with the laser. Thicker skin or skin with more severe lesions requires a greater number of passes. The pulses from the laser may sting or burn slightly, or you may feel a snapping sensation against your skin. Laser resurfacing is usually done in a doctors ofce or out-patient surgery center. Laser resurfacing may be used to remove or improve the appearance of: Wrinkles Supercial scars caused by acne, surgery or trauma that are not growing or getting thicker Color (pigment) changes or defects in the skin, such as liver spots (lentigines), port-wine stains or coffee spots. (Any growth that could be malignant should be evaluated using a biopsy before laser resurfacing is done.) In general, laser resurfacing tends to have good results with fairly low risks. Wrinkles caused by aging and long-term sun exposure, such as those around the eyes and mouth, respond well to laser resurfacing. The long-term results for these types of wrinkles are unknown, and you should keep in mind that new wrinkles will probably appear as your skin continues to age. Wrinkles caused by repeated movement and muscle use (such as those on the forehead or along the sides of the nose) may be improved but not eliminated. They often come back months or years after treatment because the muscles continue to perform the activities that caused the wrinkles before treatment. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. He is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park, and may be contacted at 423-648-4011.

Your surgeon ... your choice!

by James E. White, M.D., F.A.C.S.

health & wellness

Here are some warnings to consider: Avoid any doctor if he or she is unwilling to answer your questions. Avoid any doctor who is impatient, does not explain things fully or with whom you feel uncomfortable. Avoid any doctor who does not have a professional ofce or a professional personal appearance. Avoid any doctor whom you feel is pressur-ing you into adding unnecessary procedures. Spend extra time praying for a real peace about your nal decision. The most important thing in choosing your doctor is to remember that the decision really is yours ... so only you can make the right one. n

WOMANS WAY - March 2008

25

efore embarking on your search for the right doctor for your surgery whether elective for cosmetic reasons or necessary for medical reasons there are some steps you should take. The rst step to choosing your doctor is to develop a list of names. Where should you begin to look? There are a number of ways to build your list of doctors, and these include asking friends, other doctors you trust, hospitals and ethical cosmetic medical surgery associations. When acquiring names of doctors from friends, it is wise to remember that every surgery is unique just as every person is unique; therefore, your surgery may not turn out the same as your friends. The most advanced source to find surgeons is on the Internet. Why? People can determine a lot about their potential doctor without having to leave their home. This

information is literally at their ngertips. Now with your initial list in hand, begin to cross off unsuitable candidates. Youll want to check all the credentials of the doctors on your list so you should be prepared for some time-consuming work. Good credentials are essential. The letters FACS indicates that the surgeon is a fellow of the American College of Surgeons and is board certied. When checking prospective doctors training, remember that training is important; but even poorly trained surgeons can be board certied. You should also check the facility in which the doctor does his/her surgery. Most doctors who perform surgery will do so in an appropriate setting. Some procedures can be very successfully and safely performed in a non-hospital surgical ofce facility. Other more advanced procedures are usually performed in an out-patient surgical facility (hospital or medical surgical center). Now that you have narrowed your list to a handful of potential doctors, the next step is to set up a consultation appointment. This is your chance to ask questions and take notes, so bring a notebook and pen. You will need your notes for comparison later. During your consultation, you will be given the opportunity to ask questions, so whatever you do, dont miss out on this crucial way to get the information you need. Prepare your questions beforehand.

Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. He is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park, and may be contacted at 423-648-4011.

beauty & fashion

by James E. White, M.D., F.A.C.S.

WOMANS WAY - February 2008

Minimal invasive tumescent liposuction

tumescent technique in the 1980s. This technique has allowed liposuction to be performed with the patient under local anesthesia while minimizing blood loss and the risks of general anesthesia. Since its inception, liposuction performed with the tumescent technique has had an excellent safety prole. Traditional liposuction cannulas (stainless steel tubes) have a relatively large diameter and remove large volumes of fat rather quickly. However, with the use of large cannulas (diameter greater than three millimeters), there is an increased risk of irregularities and depressions in the skin post procedure. The tumescent technique permits the use of small microcunnulas which in turn yield smoother cosmetic results. Microcannulas with a diameter less than three millimeters allow fat to be removed in a smoother and more uniform fashion. Some surgeons prefer larger cannulas under general anesthesia because it allows liposuction to be performed more quickly. But with any artistic media, quick is not necessarily better. With general anesthesia, pain is apparent the moment that the patient awakes from anesthesia; these patients usually require narcotic medications for pain control. Patients who undergo tumescent liposuction generally do not require narcotic medications post procedure as the tumescent anesthetic effect may last as long as 24 hours after completion of the liposculpture. The tumescent technique for liposuction is unquestionably the safest form of liposuction when performed correctly (not excessively). As opposed to general anesthesia techniques for liposuction, there have been no reported deaths associated with tumescent liposuction totally by local anesthesia techniques. Tumescent liposuction patients must have realistic expectations. The ideal candidate is only 20-30 lb. overweight with focal adipose accumulations unresponsive to diet and exercise. Common anatomic areas for liposuction include the upper and lower abdomen, the anks (love handles), breast, outer and inner thighs, inner knees, arms and back, the neck, ankles and calves. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. He is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park, and may be contacted at 423-648-4011.

iposuction is the most commonly performed cosmetic procedure in the United States. Liposuction or liposculpture is dened as the removal of fat from deposits beneath the skin using a hollow stainless steel tube (called a cannula) with the assistance of a powerful vacuum. Liposuction can be accomplished either with the use of general anesthesia in a hospital/ outpatient surgery center, or with heavy IV sedation, or totally by local anesthesia in a surgery ofce setting. Tumescent liposuction refers to a technique of liposuction that uses larger volumes of very dilute local anesthesia uid which is injected into the fat, causing the targeted areas to become tumescent, or swollen and rm. Along with the tumescent effect, the area and covering are anesthetized or totally numb. If used in safe doses, large areas of fat can be removed using local anesthesia alone in a surgery ofce setting without the need for general anesthesia. The ideal candidate for tumescent liposuction is physically t and eats well-balanced meals, but is unable to reduce a fatty deposit that is well localized and often seems to involve a genetic susceptibility. In the past, surgeons completed liposuction under general anesthesia removing large volumes of fat at one mega surgical session; the surgery required blood transfusions because blood loss in the aspirate was signicant. Dr. Jeffery Klein, a dermatologic surgeon, is credited as the originator of the

WOMANS WAY - January 2008

Endovenous laser therapy for varicose veins

by James E. White, M.D., F.A.C.S.

health & wellness

21 be the right course of action for you. Most insurance carriers and Medicare cover payment for varicose vein therapies as long as it is medically necessary and not just for cosmetic reasons. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. He is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park, and may be contacted at 423-648-4011.

p to 40 percent of women and 18 percent of men have problems with severe varicose veins. Slow stagnate venous blood return to the heart often causes leg aches, burning pain, stinging pain and, with time may lead to nonhealing skin ulcerations of the distal limbs. The bulging blue and sprawling ropy varicose veins that prompted your no shorts rule can now be effectively resolved without fear of surgery, pain or long recovery periods, thanks to endovenous laser treatment (EVLT). Before EVLT, vein stripping surgery was the mainstay of vein therapy, along with compression stockings. In place of the stripping surgical procedures that required the leg to be cut open and faulty veins to be cut out, the new EVLT laser procedure is minimally invasive and neither is necessary. Evaluation of symptomatic varicose veins starts with a detailed history and physical examination. A detailed ultrasound review of the lower extremities is completed to map out the limb veins to determine the site of the faulty valves and their relationship to the varicose veins. The veins are not constant like arteries; each person has unique vein patterns and unique varicose vein problems. A personalized

attack plan is necessary with ultrasound mapping to plan efcient eradication of the problem varicose veins. The endovenous laser treatment costs less than traditional stripping surgery for varicose veins and usually takes less than two hours to complete. EVLT can be administered in an outpatient setting without general anesthesia and minimal scarring. Ultrasound is used to map out the main veins at the time of EVLT. After a local anesthetic is applied, a thin laser ber passes through a needle injected into the leg (usually near the knee). The faulty vein or veins are then sealed using high energy laser techniques. The limbs are then wrapped for a short period of time with compression wraps. Sometimes, EVLT is used in conjunction with sclerotherapy where a sclerosing solution is injected into small spider veins. This causes the small veins to seal, allowing for a better cosmetic nal result. But, before you stop shopping for shorts again, your condition rst needs to be properly evaluated to ensure that you are a candidate for EVLT laser therapy. This procedure is not for spider veins or for cosmetic reasons. The patients who are best candidates for EVLT laser therapy have significant ropy varicose veins which cause the symptoms of burning, stinging, heavy leg sensations along with leg swelling, and who have failed more conservative treatment options. Not every patient is a good candidate for EVLT, but it does work well for most. Traditional surgery still has its advantages for some (more severe) cases. Based on physical exam and a detailed ultrasound, your physician should be able to nd out if the EVLT procedure would

WOMANS WAY - December 2007

Hope in a jar
by James E. White, M.D., F.A.C.S.

beauty & fashion

Coffee berries contain high levels of antioxidants. But are these and other antioxidant advances enough to guarantee anti-aging results? Before you reach for hope in a jar, take a critical look at your facial skin. If you have never used anything on your face, you are probably more likely to see results simply because you are doing something for your skin. A Consumer Reports investigation found the current crop of antiaging creams fall short of delivering on their promises a conclusion shared by some cosmetic doctors. Cosmeceuticals can do some wonderful things for the skin by diminishing brown spots, improving skin texture and making the skin feel smooth again. Cosmeceuticals have limited effects in lling wrinkles. Until published medical studies are available, it may be up to consumers to decide for themselves if even the cosmetic results have merit from the cosmeceutical. The best hope in a jar at this point: 1) stay out of the sun; 2)wear sunscreen; 3) keep your skin well moisturized; 4) use estrogen replacement. Are we closer to the proverbial Fountain of Youth? The answer, it seems, depends on whether you need a trickle or a roaring river from the fountain. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. He is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park, and may be contacted at 423-648-4011.

19

ew anti-aging skin creams claim to do as much as medical and surgical procedures, but can they really deliver the same wrinklerelaxing, age-defying re-sults as some pricey ller injections, Botox or surgery? If youre skeptical about what you see in print or on the internet, youre not alone. Unlike medications, cosmeceuticals are not regulated by the Food and Drug Administration (FDA). Drug companies are required by the FDA to perform extensive trials and testing prior to claims of performance or efcacy of the medication. The cosmetic industry has little or no regulations; making it difcult to nd substantial trials and testing of creams, serums, potions and cosmeceuticals, having stated the disclaimer for testing. Skin cream technology for the most part is focused on a few areas: collagen production, healing and antioxidants. One of the major ways our skin ages is through the loss of collagen, a naturally occurring substance that keeps our skin looking plump, lifted and smooth. The collagen is a scaffolding which supports our skin. As time ticks by, we

lose some collagen because of natural aging, sun exposure, smoking and pollution. These exposures increase the rate at which our natural cellular process occurs. The cell aging process releases molecules called free radicals or oxidants into the skin. The link to aging? Free radicals attack and destroy additional collagen support structures, and without that support, skin sags and forms wrinkles. Many creams claim to increase the collagen content of our skin. One problem, penetration of the outer skin. Our skin is a barrier maintained between us and the environment which makes us water tight, limiting water based liquids from entering or exiting the body. So how do creams penetrate the skin? Water based moisturizers stay on the surface with little penetration of the outer surface of the skin. Deep penetration into the skin requires more expensive synthetic peptides with fatty acids. The fatty acids allow products to be transported to the deeper layer of skin. Once the product is delivered to the skin, companies claim increased collagen production in 4-12 weeks. Limited studies have shown that collagen is produced with the creams, but not anywhere near what happens during collagen production with wound healing. On the front lines of anti-aging is a group of antioxidants. Antioxidants attack oxidants, free radicals before they have a chance to destroy our collagen supply. An ingredient derived from the coffee berry is now hailed as the strongest antioxidant with the most powerful anti-aging ingredient to date. The same coffee which wakes you up in the morning, may also add a kick to your complexion.

health & wellness

by James E. White, M.D., F.A.C.S.

WOMANS WAY - November 2007

Skin cancer: See spot. See spot change. See a surgeon.

as sunlamps and tanning beds, have been linked to causes of skin cancer. People who live in areas that get high levels of UV radiation from the sun are more likely to get skin cancer. And, as you guessed, in fair skin colored people. Most skin cancer appears after age 50, but the suns damaging effects begin at an early age. Therefore, protection should start in childhood. Protective clothing such as sun hats and long sleeves can block out the suns harmful rays. Also, lotions that contain sunscreen can protect the skin. Sunscreens are rated in strength according to a sun protection factor (SPF) which ranges from 2 to 30 or higher. Those rated 15 to 30 block most of the suns harmful rays. Surgery is often used as a treatment for skin cancer. There are several types of surgery depending on the stage and location of the cancer. Shave biopsy simple excision and formal excision of suspicious skin lesions are the rst steps for diagnosis and treatment. Management of skin cancer is based on the cell type, location of the tumor and extent of the tumor. Superficial skin cancers can often be cured by surgical excision alone. Dysplastic or abnormal appearing moles are sampled using a scalpel. The skin sample is sent off for a more detailed microscopic control so it can be determined whether all cancer has been removed. When the doctor suspects a cancer has gone beyond stage 0, samples of the nearest lymph nodes may also be taken using a biopsy. The surgery is normally done using local anesthetic as an in-ofce procedure. The removed moles or skin samples will be analyzed and if they prove to be melanoma cancer, it may be necessary to have a second surgical operation to remove the entire melanoma, including some of the health skin around it to allow for safety margin. Possible treatments for advanced melanoma tumors are chemotherapy or radiation. At least 80 to 90 percent of all patients who have been diagnosed with a melanoma cancer can be cured with a good prognosis. Develop a regular routine to inspect your body for any skin changes. If any growth, mole, sore or skin discoloration appears suddenly or begins to change, see a surgeon. Each of the skin cancer types can be treated if detected early. The ABCs of skin cancer include: A - Asymmetry. You should notice the general look of your moles or growth. For example, if one half of the mole or growth does not match the other half. B - Border irregularity. If the edges of the growth are ragged, notched or blurred. C - Color. The pigmentation of the growth is not uniform. Shades of tan, brown and black are present. Dashes of red, white and blue add to the mottled appearance. D - Diameter. A width greater than six millimeters (about the size of a pencil eraser), can be an indicator of an abnormal skin growth. Generally, any new mole growth or non-healing skin ulcer should be a concern. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. He is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park, and may be contacted at 423-648-4011.

bout a million people in the U.S. are diagnosed with skin cancer every year. According to current estimates, 40 to 50 percent of Americans who live to age 65 will have skin cancer at least once in their lifetime. Although anyone can get skin cancer, the risks are greatly increased if you have fair skin that freckles easily often with red or blond hair and blue or lightcolored eyes. Fortunately, even though skin cancer is the most common type of cancer, it is not the reason for most cancer deaths. The two most common kinds of skin cancer are basal cell carcinoma and squamous cell carcinoma often called non-melanoma skin cancer. Basal cell carcinoma accounts for more than 90 percent of all skin cancers in the U.S. It is a slow-growing cancer that seldom spreads to other parts of the body. Squamous cell carcinoma also rarely spreads, but does so more often than basal cell carcinoma. Melanoma is another type of cancer that occurs in the skin in the melanocytes or the pigment cells. Of the three, melanoma is the most aggressive, and with metastasis can result in death. Ultraviolet (UV) radiation from the sun is the main cause of skin cancers. Even articial sources of UV radiation, such

WOMANS WAY - October 2007

Melasma: The mask of pregnancy

by James E. White, M.D., F.A.C.S.

beauty & fashion

with facial peels using alpha hydroxy acids or chemical peels with glycolic acid. Yet, some of the most dramatic changes in melasma spots have been attained with laser skin resurfacing treatments. In all of these treatments, the effects are gradual and a strict avoidance of sunlight is required before, during and after completion of therapy. The use of broad-spectrum sunscreens with physical blockers such as titanium dioxide and zinc dioxide is preferred over that with other chemical blockers. This is because UV-A, UV-B and visible lights are all capable of stimulating pigment production. Say goodbye to the tan beds! Last, but not least, cosmetic makeup can be used to reduce the appearance of melasma. Melasma, though annoying, has no known relationship to skin malignancy. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. The ofce is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park. He may be contacted at 423-648-4011.

17

elasma is an acquired hyperpigmentation of sunexposed skin areas, or in plain English, dull brown spots. It presents as symmetric hyperpigmented spots which can be separated or bunched together along the cheeks, nose, the upper lip, the chin and the forehead, and can occasionally occur in other sun-exposed locations. Melasma spots are dark, irregular brown-toblack patches that gradually, over time, may develop into mask-like patterns. The exact cause of melasma is uncertain. In many cases, there is a direct relationship with female hormonal activity because melasma occurs with pregnancy and with the use of oral birth control pills. Other factors related to melasma include sun sensitizing medications, mild ovarian or thyroid dysfunction, and certain cosmetics. Yet the most important factor in the development of melasma is exposure to sunlight. Without the strict avoidance of sunlight, potentially successful treatments of melasma are doomed to fail. Tanning bed exposure has increased the incidence of melasma in the United States. Melasma, though distressing, is a benign process. Melasma is rare before puberty and most commonly occurs in women during their reproductive years. Although it can affect anyone, melasma is particularly common in women, especially pregnant women and those who are taking oral contraceptives or hormone replacement therapy

(HRT) medications. It is much more common in women than in men; in fact, women are affected in 90 percent of cases. When men are affected, the clinical presentation is identical. Melasma does not cause any other symptoms beyond the cosmetic discoloration. However, the facial discoloration can be devastating. Persons of any race can be affected by melasma, however, it is much more common in people of darker skin types than in lighter skin types, and it may be more common in light brown skin types from areas of the world with intense sun exposure. Melasma is also prevalent in men and women of Native American descent (on the forearms) and in men and women of German/Russian Jewish descent (on the face). Melasma is usually diagnosed by a physician visually or with assistance of a Woods lamp (black lamp). Under the Woods lamp, excess melanin pigments in the epidermis can be identied. Some melanin deposits are supercial in the skin while others may be deep in the dermis. The deeper the pigment deposits, the more difcult it is to treat. The discoloration of melasma usually disappears spontaneously over a period of several months after giving birth or stopping the oral contraceptives or hormone replacement therapy. Treatments to hasten the fading of the discolored patches include; topical depigmentation creams, acid peels, and laser skin resurfacing. Depigmentation creams such as hyproquinone (HQ) can be used directly on the dark spots. HQ is a chemical that inhibits a specic enzyme involved in the production of melanin pigments. Acids ointments are used to increase skin cell turn-over, pushing the brown discolorations to the surface so rapidly that it results in pigment fading. Other acid treatments are thought to decrease the activity of melanocytes or pigment cells. When topical treat-ments fail, most patients proceed

WOMANS WAY - September 2007

Fractionated skin resurfacing by cutting edge technology

by James E. White, M.D., F.A.C.S.

beauty & fashion

effective even on delicate skin areas, such as the neck, chest and hands. Fractionated laser skin resurfacing is completed with minimal discomfort. Patients experience a mild sunburn sensation for about an hour and then minimal discomfort. The treated skin will have a pinkish tone for 12-24 hours. This is a sign that the skin is healing normally. Swelling is minimal and generally resolves in 12 hours. One may apply makeup or shave soon after treatment. Some patients are able to return to routine activities the same day of treatment. Others require a little more time, depending upon their skin condition and treatment. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a variety of cosmetic procedures including facial llers, thermage and botox. The ofce is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park. He may be contacted at 423-648-4011.

s we age, the accumulative effects of wear and tear damage begin to show in our skin. We loose the glow of youth to be replaced by aged leather-like skin with areas of color blemishes. Skin resurfacing has been used to trick the body to replace the old skin with new skin. Deep chemical peels and CO2 laser skin resurfacing are techniques that have been used as ablative skin resurfacing. Basically, the upper layers of the skin are burned by the chemical peel or laser like a second-degree burn. The upper layers of skin slough off over three to four weeks, being replaced by new pink, smooth skin. The results are impressive; however, the down time and pain involved is extensive. Recent technology with laser fractionation has decreased the down time to a minor outpatient procedure with minimal discomfort, resulting in 12 hours of skin pinkness without all the slough. Laser energy is passed through a special lens causing the laser energy to fractionate into thousands of microbeams. These microbeams penetrate the upper layers of the skin surface to cause areas of microtreatment zones which the body replaces with new skin. Think of pixels in a digital photograph when you think of fractionated skin resurfacing. If you look at a

digital image in extreme magnication, youll see that the image is actually comprised of thousands of tiny spots of color (pixels). Similarly, fractionated laser skin resurfacing produces thousands of tiny treatment zones on the skin known as microthermal zones. These laser microbeams penetrate deep into the dermis and eliminate old epidermal pigmented cells. The fractionated laser is so precise that it penetrates through the outer layers of the skin as if it were a window and leaves it and the surrounding tissue completely intact. This fractional treatment allows the skin to heal faster than if the entire area were treated at once, using the bodys natural healing process to create new, healthy tissue to replace skin imperfections. Just as a damaged painting is delicately restore one small area at a time, or a photographic image is altered pixel by pixel, fractionated laser treatments improve your appearance by affecting only a fraction of your skin at a time with thousands of tiny microscopic laser spots. Fine to deep wrinkles, acne pitting scars, old surgical scars, discolorations and rough skin texture are just a few of the areas improved by fractionated laser treatments. Laser treatment targets between 20 and 25 percent of the skins surface at each treatment. Clinical studies suggest that, on average, an effective treatment regimen is four to six treatment sessions spaced about two to three weeks apart. Depending upon your condition and schedule, you and your physician may choose to space treatment sessions even further apart. Results are immediate and progressive. Optimal improvement is usually visible in four to six months after completion of the treatment series. Because fractionated laser treatments spare the healthy tissue, it is

WOMANS WAY - August 2007

Ofce-based mini facelift

by James E. White, M.D., F.A.C.S.

health & wellness

upper neck. The leftover redundant skin is then tailored to match. The incision is carefully closed using plastic surgery techniques designed to reduce tension and minimize any visible scarring. In some cases, a small incision will also be made under the chin to remove excess tissues; this tuck with liposuction of the neck and jowl area may be performed in conjunction with the mini facelift for optional aesthetic results in the neck region. Unlike the conventional facelift that may result in a pulled back appearance, the mini facelift offers very natural-looking results. Patients enjoy an overall rming of the lower facial area, noticeable jaw line denition and a more elegant neckline. Generally, the results obtained with the mini facelift are predictable and quite dramatic, sometimes erasing ve, ten, even fteen years from ones appearance. n Dr. James E. White is board certied in General Surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons. His ofce, Advanced Surgical Concepts, PLLC, Varicose Veins Solutions & Aesthetic Skin Care, offers a wide variety of cosmetic procedures including facial llers, thermage and botox. The ofce is located at 7446 Shallowford Road, Suite 205 in the Hamilton Ofce Park. He may be contacted at 423-648-4011.

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egradation of skin elasticity, deation of facial volume and descent or falling of facial structures are an unfortunate effect of aging. The traditional facelift addresses each of these issues, but with a price: down time and expense. Many men and women 40 to 65+ who dont wish to look their true calendar age consider facelift procedures to erase sagging jowls and that loose, draping, wrinkled skin under the chin. The ofce-based mini facelift is a mid-range mini surgical facelift to address the mid to lower face. The post operative effect provides a more natural appearance with limited down time when compared to other formal facelift procedures. Most traditional facelifts are performed with general anesthesia and involve multiple weeks of downtime and a long incision beginning at the upper temple and extending behind the hairline on either side of the face to the nape. The minimal incision mini facelift, which has been performed since the late 1990s, is the basis for the ofcebased mini facelift. The mini facelift proves an overall lift to the lower region of the face and upper neck, offering signicant age-diminishing effects with minimal downtime and lasting results.

The mini facelift is designed for men and women who want to stay ahead of the Ds of the aging process: Degradation, Deation, Descent. As we age, most individuals lose elasticity in their skin and develop varying degrees of descent along the jaw line and beneath the chin. The mini facelift not only tightens skin, it is designed to suspend the underlying structures of the lower face and upper neck. This suspension of the lower face offers the benet of a more youthful appearance without the wind blown look of a formal facelift. This turn back of time from the mini facelift will last until the normal aging process resumes for the individual. Lifestyle choices, heredity, bone structure, skin type and sun exposure all play a part in determining how long the mini facelift surgical results will last for each individual. The mini facelift is an outpatient procedure that usually takes one to two hours to perform, depending on age of the patient and the degree of facial correction desired. Oral pre-medications are given to help relax the patient, local block is used for the skin. A small, relaxed S-shaped incision is made beginning along the sideburn, extending along the front of the ear, around the earlobe and up to the hair line back from the ear toward the nape of the neck. Great attention is given to the placement of the incision line to provide an inconspicuous scar after healing. Short skin aps are created with meticulous care. The underlying connective tissues and facial musculatures are gently lifted and tightened using a simple suture technique. The sutures are anchored to dense tissue around the facial bones to suspend the sagging facial tissues. This suspension enhances the appearance of the jaw line and