Silicone Treatment for Scars

It’s been 3 weeks since my Mohs surgery, and I’m becoming addicted to this little tube of silicone gel that my plastic surgeon gave me to use.

“Apply this 2-3 times a day to prevent scarring and redness” he said, uncapping the tube, smearing it’s contents on my newly-healed Moh’s incision and then gently rubbing it in. “Rub it in, pressing down to the bone. Let it dry, then you can apply make-up over it.”

As I left, his nurse commented – “Ah – I see you got “The Tube”. He loves that tube!”

It’s pretty cool that I can actually do myself to help the healing process along. It’s also oddly comforting to stroke my scar and feel the silicone covering on it. But the other night, as I applied the silicone gel, I found myself curious as to how this stuff worked. Was it just a little plastic surgery witchcraft or was it really doing something to prevent scarring and redness? So I headed to Pub-Med and did a little reading.

What I found was that this stuff really does work. Numerous controlled trials have shown that silicone sheeting treats hypertrophic scars or keloids and prevents such scars in the first place if used prophylactically. There is less data on silicone in other forms, such as gels and creams, but several studies suggest that they work as well as the sheets. My tube is just one of many brands of silicone products that now sell over the counter. I don’t know if there’s a difference between brands, thought I suspect they are probably all the same.

How do silicone sheeting and gels work to prevent scars?

No one knows for sure, but here is the current thinking – When a wound heals, the new skin that is made is immature and not as good an osmotic barrier as older skin. Thus, water is lost from the deeper layers of the skin. It is theorized that water loss from the stratum corneum leads to production of cytokines, which in turn increases the amount of collagen laid down by the fibroblasts there. (Collagen is the stuff of which scars are made.)

Silicone sheets and gels are thought to create an osmotic barrier that prevents evaporative loss of water from the wound, thus leading to decreased collagen and scar formation. Silicone sheets are the most studied, but are harder to use on the face where visibility is a problem and on joints where movement dislodges them. Silicone gels have the advantage of being easy to use, and the gel dries nicely to create a countered covering. Some specialists recommend using the sheets at night and the gels during the day.

Can’t I just Use Vaseline?

Nope. Apparently, Vaseline does not work to prevent scar formation. Nor do plastic sheets and other occlusive dressings. There is something about the osmotic barrier in silicone sheets and gels that makes it “just right” for the job. That something may not be the actual silicone itself, but the vehicle or matrix that it forms. Indeed, more recent studies using some non-silicone gels have shown similar efficacy to silicone, suggesting that the gel’s the thing.

What about steroid injections?

The other well-proven treatment for hypertrophic scars is steroid injections. But steroid injections are used on already formed scars, as opposed to silicone gel, which can be used to prevent scarring.

How about the rubbing?

The rubbing that I am doing is also helping my wound heal prettily by preventing the formation of collagen bands in the scar.

This young girl, whose parents have a wonderful site showing the evolution of her cleft lip and palate from birth through repair to age 10, rubbed cocoa butter on her scar. She looks great – a testimony to the use of pressure and rubbing (or 10 year old skin…)

Comments? Corrections?

This is my own little foray into a completely different field of medicine from that for which I was trained, so I hope that I have not made any glaring errors. I would love to know what my plastic surgery colleagues think about this topic (RL?). I don’t know, for instance, if one brand or type of gel is better than another, or what one should look for in a gel to be sure it will work.

That’s it? No shocking photos of scar tattoos?

Oh, all right – here. Just don’t say I didn’t warn you.
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Part 5 here

The Power of the Medical Blog

Dr Crippen has managed to get the BBC to change a headline, merely by criticizing it in his blog. He then got an apology from the writer of the article in question, which was about how MRI has a high false positive rate. This, of course, is not news. It is why MRI is not yet ready for prime time breast cancer screening. But like any good news outlet, the BBC had managed to make this piece of information sound utterly frightening, with the headline “Mri scans commonly wrong”.

This is not the first time the BBC has responded to Dr Crippin’s criticism by changing a story.

I find this entire episode amazingly encouraging. Our voice can matter, folks. Keep writing, keep taking on the powers that harm, and we will be heard.

Decorating Update

I promised photos of the paint job, and here they are.

The final color we chose was Benjamin Moore’s Richmond Gold with Cream Froth for the trim and contrast walls. (It’s really hard to get a photo that captures the color as it looks in real life, so I’m putting up a few to give you the idea. The first one below is in daylight and all the rest are in the evening.)

And then I saw this amazing wallpaper, and had to have that too.

I have to admit that as the paint was going up, I was a little scared that I did not like it. But as soon as things got up on the walls and the rugs down, I knew we had made the right choice.

Our prior color had been yellow, which I loved, but I think this new look is better. Look at the before photo below to see what I mean. (Don’t think the place looked this good before we painted – that before shot is almost 10 years old…)

Here another shot…

Need to get a runner for that back hall…

The living room is still a work in progress. We’re looking for something new to hang on the wall over the sofa. And a wood coffee table. And some new lamps. And a bigger rug. And another big comfy chair…

Thanks again for everyone’s suggestions and support through this process. I feel as though I’ve given birth.

Grilled Sausages with Figs

This is a little variation on a Tapas recipe I found on Epicurious. It was my contribution to Easter Brunch (with a little help and some beer from brother Joe), and went well with the quiches, Apple French Toast and salad that were served. This sauce was so incredible, I’m trying to think of other ways to use it.

Grilled Sausages with Figs for a Crowd

To make a slightly classier version for a smaller group, use less sausages, cut them lengthwise and plate individually with a few figs and the sauce drizzled over them.

2 cups red wine vinegar or balsamic vinegar (I used a half and half mixture of both)
1 1/2 cups sugar
12 oz. dried black Mission figs
1 cinnamon sticks
3 whole cloves
Pinch of salt
2 teaspoons water
1 teaspoon cornstarch
20 assorted sausages (Sweet Italian were the best)
Enough beer to cover the sausages in a saucepan plus a little water

Heat vinegar with sugar over medium heat till sugar is dissolved. Add figs, cinammon stick, cloves and a pinch of salt. Bring to boil; reduce heat to medium low and simmer until figs are softened and vinegar is slightly syrupy, about 45 minutes to an hour. Mix water and cornstarch in small bowl; stir into fig mixture. Boil and stir to thicken slightly, about 1 minute. Let stand 1 hour. Fig sauce can be made 1 day ahead. Cover and chill.

Bring the beer to boil in a medium sized saucepot. Add sausages and simmer for 15 minutes while you fire up the grill. (If you need more liquid, add a little water). Remove sausages from beer, shake dry and grill, about 5 minutes per side, till cooked through and brown.

To serve : Slice up sausages, toss with figs and sauce and serve in a bowl family style.

Elephant Walk (with recipe)

Dounle click the arrow to watch the elephants enter Manhattan!

If you found yourself with nothing to do around 1 am on Tuesday, you could have met us in Midtown Manhattan for one of those Only-in-New York events – the Ringling Bros. Circus Annual Elephant Parade.

The elephants come into New York via train, and then need to get from Queens to Manhattan. Apparently the only way to do it is to walk. So the NYC DOT closes the Midtown Tunnel to traffic from midnight to 2 am and the elephants walk right into Manhattan and across 34th Street to the circus grounds at Madison Square Garden!

Animal rights activists aside, watching the elephant walk was one of the most fun things we’ve ever done as a family. I just can’t believe it took us 15 years to finally do it. (Although having to stay up past 1am on a school night may have had something to do with that…) Thanks to Mr TBTAM for being the energetic one to get us all going.

There were no more than a few dozen folks at the Midtown tunnel exit on Third Ave when we arrived around midnight, making it a great spot to wait for the privilege of being among the first to see the pachyderms as the exited the tunnel at 1 am. Then it was a short run up to 34th Street (those elephants move a lot faster than you think!), to join the many hundreds who gather along the rest of the route. It’s quite a surreal experience, actually, to see the animals strolling along 34th street, not to mention the fact that so many folks are out there with you at that ungodly hour.

Of course, I needed to cook a little something to commemorate the event, and found a wonderful dish from the Elephant Walk Cookbook from the chefs at this renowned French-Cambodian restaurant in Cambridge, Mass. I’ve never eaten at the Elephant Walk, but since we’ll likely be heading up to Boston on college tours next month, I think I’ll check it out then. From the reviews I’ve read, the cookbook also looks worth getting.

Elephant Walk Butternut Squash and Pork Stir Fry

This is a very simple dish, but extremely flavorful. I thought about adding more things to increase its complexity, maybe some peanuts in honor of our long-nosed friends, but in the end just left it alone as it was. (Well, I did use red pepper flakes instead of black pepper and increased the scallions…) Amazingly, my younger daughter, whose palate can be a bit limited, loved this meal. Maybe it’s the magic of the elephants….

3 tablespoons vegetable oil
3 garlic cloves, smashed
1/2 pound pork tenderloin or fresh ham, cut into small strips
2 tablespoons fish sauce
1 teaspoon sugar
1 1/4 pounds buttercup squash, peeled, seeds scooped out, julienned
4 scallions, cut into 1 1/2 inch pieces
1/4 teaspoon red pepper flakes
Cooked Basmati Rice

Heat the oil in a large skillet or wok over medium-high heat and sauté the garlic until golden brown, 5 to 10 seconds. Add the pork, stirring well, then add the fish sauce and sugar. Fold in the squash gently and stir-fry until it is cooked through but still slightly crunchy, 4 to 5 minutes (or longer if you prefer a soft texture).

Add the scallions and pepper and stir well. Serve hot with rice.
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Recipe found at Rediff.com

Elephant Walk (with recipe)

Dounle click the arrow to watch the elephants enter Manhattan!

If you found yourself with nothing to do around 1 am on Tuesday, you could have met us in Midtown Manhattan for one of those Only-in-New York events – the Ringling Bros. Circus Annual Elephant Parade.

The elephants come into New York via train, and then need to get from Queens to Manhattan. Apparently the only way to do it is to walk. So the NYC DOT closes the Midtown Tunnel to traffic from midnight to 2 am and the elephants walk right into Manhattan and across 34th Street to the circus grounds at Madison Square Garden!

Animal rights activists aside, watching the elephant walk was one of the most fun things we’ve ever done as a family. I just can’t believe it took us 15 years to finally do it. (Although having to stay up past 1am on a school night may have had something to do with that…) Thanks to Mr TBTAM for being the energetic one to get us all going.

There were no more than a few dozen folks at the Midtown tunnel exit on Third Ave when we arrived around midnight, making it a great spot to wait for the privilege of being among the first to see the pachyderms as the exited the tunnel at 1 am. Then it was a short run up to 34th Street (those elephants move a lot faster than you think!), to join the many hundreds who gather along the rest of the route. It’s quite a surreal experience, actually, to see the animals strolling along 34th street, not to mention the fact that so many folks are out there with you at that ungodly hour.

Of course, I needed to cook a little something to commemorate the event, and found a wonderful dish from the Elephant Walk Cookbook from the chefs at this renowned French-Cambodian restaurant in Cambridge, Mass. I’ve never eaten at the Elephant Walk, but since we’ll likely be heading up to Boston on college tours next month, I think I’ll check it out then. From the reviews I’ve read, the cookbook also looks worth getting.

Elephant Walk Butternut Squash and Pork Stir Fry

This is a very simple dish, but extremely flavorful. I thought about adding more things to increase its complexity, maybe some peanuts in honor of our long-nosed friends, but in the end just left it alone as it was. (Well, I did use red pepper flakes instead of black pepper and increased the scallions…) Amazingly, my younger daughter, whose palate can be a bit limited, loved this meal. Maybe it’s the magic of the elephants….

3 tablespoons vegetable oil
3 garlic cloves, smashed
1/2 pound pork tenderloin or fresh ham, cut into small strips
2 tablespoons fish sauce
1 teaspoon sugar
1 1/4 pounds buttercup squash, peeled, seeds scooped out, julienned
4 scallions, cut into 1 1/2 inch pieces
1/4 teaspoon red pepper flakes
Cooked Basmati Rice

Heat the oil in a large skillet or wok over medium-high heat and sauté the garlic until golden brown, 5 to 10 seconds. Add the pork, stirring well, then add the fish sauce and sugar. Fold in the squash gently and stir-fry until it is cooked through but still slightly crunchy, 4 to 5 minutes (or longer if you prefer a soft texture).

Add the scallions and pepper and stir well. Serve hot with rice.
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Recipe found at Rediff.com

Estrogen and Memory

Primate brain before (left) and 48 hours after estrogen (right)
Today’s WSJ Online has a great article on estrogen and memory. It’s mostly anecdotal evidence from physicians describing a phenomenon that those of us who treat a lot female patients see. That is, in some women, estrogen seems to help the brain function. It’s an article worth reading.

Just to add a couple of my own anecdotes to the pile…

The Breastfeeding writer

A 35 year old newspaper columnist, 8 weeks post-partum and breastfeeding, calls me. “I can’t write! I’m sitting here staring at my computer and nothing is happening. I have a deadline tomorrow and I just can’t find the words I need to express myself.”

Breastfeeding is a time of low estrogen levels, and breastfeeding women will often complain of vaginal dryness. But this was a new complaint I had not heard before. She sounded just like my menopausal patients. So I gave her some estrogen. She called me several days later – “It’s like someone turned on a switch! I’m back!”

The Peri-menopausal Exec

49 years old, high functioning, multi-tasking, juggler of many things. This is a woman who can talk on the phone while typing an important email and hold a meeting all at the same time. Carries names in her head like a roladex.

Her ovaries were removed 6 months ago along with a hysterectomy. A totally unnecessary piece of surgery, by the way. All she needed was the uterus removed, but her doctor told her that if she were his wife, he’s take out the ovaries, so that’s what she agreed to…

Now, she finishes the day and realizes she has barely gotten anything done. Someone who could easily do three things at once is now down to one-at-a-time tasking, and even that is going slowly. “I can’t keep up with my pace. My brain just won’t make the connections fast enough” All her lab values are normal, including her thyroid functions and hematocrit.

We give her estrogen. Within a few weeks, she is almost back to her old self.

The Human Research Data

Now, these two stories are not typical. Most peri-menopausal and menopausal women don’t have such dramatic deficits or recovery. Some have no symptoms related to brain function at all. Those that do typically complain of problems with word recall or names, or a feeling of “fuzziness” in the brain. “Clogged up” is a phrase I hear often. These symptoms are sometimes relieved with estrogen, and sometimes they are not.

Results from research studies have been contradictory. No studies have found an effect of estrogen on memory in populations of women undergoing normal menopause. But in studies of women undergoing surgical menopause, estrogen has been found to improve memory, particularly verbal memory.

In my opinion, most of the studies that have been done to date have not used testing that measures the kind of brain function estrogen seems to affect. Most have used dementia screening or Alzheimer’s screening or basic tests of overall memory.

Menopausal women are not complaining about dementia or losing their memory. What they complain about is problems finding words and names, problems making sophisticated verbal constructions, problems writing fluently, and problems multitasking. And fuzziness.

I don’t think we have a good objective measure of brain fuzziness.

The Primate Data

Whenever I think about estrogen and the brain, I think about monkeys. If you look at the brains of primates, what you find is that estrogen increases the number of dendritic outgrowths – connectors, if you will – between brain cells. (They’re the little red things up there in the photo). The increase in dendritic outgrowths is rapid – within 24 -48 hours of giving estrogen, there is a measurably dramatic change in the number of connections between brain cells.

Take away estrogen, the number of brain cell connections decreases. Interstingly, if one adds progesterone continuously to the regimen, you attenuate the estrogen effect.

It’s the best evidence I’ve seen to date that correlates with what my patients tell me. Loss of estrogen leads to loss of connectivity between brain cells. It takes longer to find a word, find a name. Harder to write. Harder to multitask.

Now What?

I’m not going to belabor the whole “Should I take HRT?” question here. You can read what I think about that issue here.

What I will say is that the story on estrogen is far from over.

What I believe is that for some women, estrogen is important for brain function. Who those women are, how to identify them and how to weigh this against the potential risks of HRT as we now know it, are all questions whose answers are too individual to answer for women as a whole.

Stay tuned…
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Photo from J Neuropsychiatry Clin Neurosci 13:313-317, August 2001

Treating Infertility by Flushing the Tubes

It’s one of those interesting phenomena that most gynecologists have seen in their practice at least once. You do an HSG, and the woman with longstanding infertility becomes pregnant the very next cycle!

HSG – that’s short for hysterosalpingogram, a study in which dye is injected through the uterus into the fallopian tubes to see if they are blocked or open.

Post-HSG pregnancies happened often enough that we all thought thought it must be a real effect of the HSG. We theorized that the flushing of the tubes must be opening up a previously undiagnosed blockage of the tubes. But we secretly wondered whether what we were really doing was flushing out the bad humors.

As it turns out, our experiences were indicative of a real phenomenon, and our secret theory was not so crazy. In the past decade, several randomized studies have confirmed that doing nothing but performing an HSG increases pregnancy odds by as much as two to three times. (Cochrane review here). Studies have also confirmed that tubal flushing decreases the concentration of cytokines and other inflammatory proteins in the fallopian tube, and reduces sperm phagocytosis (ie, bad humors).

Now, some docs are wondering if flushing of the tubes could become more than just an observed phenomenon but a planned part of infertility treatment.

Researchers at the Karolinska Insitute in Stockholm have published a nice little study in which they randomized couples with unexplained infertility to one of two treatment arms – (a) Clomid (a drug that stimulates ovulation) plus intrauterine insemination or (b) the same plus pertubation (flushing) of the fallopian tubes with an anesthetic solution just prior to insemination.

Among the 67 patients whose tubes were flushed, there were 10 clinical pregnancies (15%) vs only 2 (3%) in the 63 women whose tubes were not flushed, a statistically significant difference.

But before you get yourself too worked up about these results, it’s worth noting that a fertility-expert friend of mine says that the pregnancy rate in the control group was unusually low, and suspects that this may make the intervention look better than it really is.

In addition, the authors point out that the overall pregnancy rates using this technique are significantly lower than the 30% pregnancy rate expected with IVF in the same population of patients. But their lower tech method is cheaper and faster, and they propose that it may be appropriate for couples who either don’t want IVF or want to do something while they are waiting for IVF.

It’s an interesting idea that needs a bit more study before implementing it outside a research setting. Stay tuned…
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Disclaimer – I am NOT a fertility expert, just a plain-old gynecologist reading the latest literature and doing a little wondering. My little musings should not be mistaken for medical advice. The best person to decide your teatment is your doctor, not me.

Living a Life After Cancer

I have some amazing patients.

Take Carrie Wells. Carrie’s a breast cancer survivor who has done so much more than survive – she’s moved beyond her diagnosis and used what she has learned to master the art of living a life.

If you do not let cancer dissolve your spirit, it will be the doorway to learning… I faced my long, losing battle to control change, to put reason to the cancer, and decided to heal.

Carrie credits her energy for life to her experiences at the Life Beyond Cancer Retreat in Arizona in 2004. It was there that she healed, de-stressed and discovered that she had the inner resources and energy to create and live a life after cancer.

Such retreats make so much sense. So many women with cancer get their diagnosis and then move through treatment while working either in or out of the home, leading busy lives and often caring for children and even parents while fighting the battle of their lives.

You know these women – heck, you may be one yourself. Fitting in radiation treatments before work or during lunch hours, heading back to work two weeks after surgery, popping chemo pills between meetings. Most barely take the time to heal physically, let alone emotionally and spiritually. Certainly few take the time to rejuvenate and regroup.

Carrie is determined to help other women heal the way she has. She has created a web portal called Survivor’s Retreat, where cancer survivors can search for retreats, workshops and other destinations that offer healing experiences, relaxation, exercise or just plain pampering – whatever you think you need to heal. You can search on Carrie’s site by location, cost and type of retreat to find just the right escape you need.

Do send a link to the site to a friend or loved one dealing with a cancer diagnosis. And if you know someone who sponsors a retreat, let Carrie know so she can include it on the site.

Carrie’s just been named as one of 25 Yoplait champions, an award that honors “ordinary women and men from across the country doing extraordinary things in their local communities to help in the fight against breast cancer”.

See? Amazing.

Mohs Nose – Part 3 or Okay, I’m Over Myself..

The week went just fine. I wore the band aids on my nose, and the world did not come to an end. I made it a point to briefly explain and apologize for my appearance at the beginning of each patent’s visit so as to get it out of the way, but the truth is, they barely noticed. After all, it’s about them, not me, isn’t it? And that’s just the way it’s supposed to be..

At work, the staff I work directly with were great. My colleagues barely said a word, but after a meeting, one colleague did ask what happened, but very carefully. Compare that to my choral rehearsal, where the whole place went into the “Oh my god, what happened? Are you all right?” mode.

It’s funny – at work, we don’t talk about anyone’s health. The same colleague who asked me about my nose revealed in the same conversation that she had had a cancer last year. I had no idea. It could be because HIPAA has squelched all that conversation. But the truth is that few of us docs are really truly friends, and have little to no time to become friends. In addition, years of little battles over space and autonomy and time and money and workload have whittled away at what room we have in our hearts for each other. Those friendships that do form are often woven with shared dislikes and negative opinions about other colleagues. I’ve seen this in enough places I’ve worked to know it is not unique to my current place of employment. Academic medicine is just like that. It’s sad, really…

Anyway, the stitches are out and the steri-strips are on. Here’s a photo, but you really can’t see much because of the steri strips. I’ll post another next week when the steri-strips come off.

Thanks again to all of you, and to all my friends and family for their support this past week. It’s meant a lot to me.
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Part 4 here