Eye clinic in Port-au-Prince.

First, I wanted to address the title of this post.  The “Third World” is actually an outdated and useless term, which came about after World War II to describe countries that neither belonged to NATO or the communist bloc.  This third group of countries were very often also poor and the two labels become synonymous. What the term does however, is lower these countries to a status unbefitting of the people living there.  There is no doubt that Haiti is poor, but to cast it and its people aside as being in a different world is unfair and detrimental to understanding their plight.  It takes around an hour to fly from Miami to Port-au-Prince, hardly a world away (remember when Haitians were crossing to Florida in rafts). In truth, they live in exactly the same world as the rest of us, that world just hasn’t given them as much to work with.  As a kid, I never wondered if my next meal was coming, or if I’d have access to clean water. The power was on 99.9% of the time, along with either the A/C or heat.  And if, God forbid, I or someone I knew got sick, I knew every possible treatment was available to them.  These all seemed to be my right as a human.  So when you see people who have little to no hope of achieving many of these basic rights, you can’t help but wonder what is going on in this world.

The good news is, I also saw hordes of people, mostly from the US and France, visiting on mission trips.  Most were with church groups building schools and churches, establishing water sources and doing ministering.  Everyone was jazzed about the difference they made and many talked about what they were planning for their next trip.  You can’t help but think with all this help coming, more than 3 years after the earthquake, it is only a matter time before momentum brings real change to Haiti. Just sending money to their government won’t help, just ask Somalia, Ethiopia, Sudan….

Just a couple of stories of patients I met.  I saw quite a few children with facial deformities due to tumors or hemangiomas, but also due to trauma.  Trauma was the theme of the visit.  This great young kid had been hit in the face by someone a few weeks earlier and had a persistently swollen right eye. I was worried about a foreign body.  During surgery, I encountered a hard mass against his eye and tenting the conjunctiva out where it appears red and swollen in the photo.  It turned out to be a chunk of bone that had been dislodged from inside his eye socket. No one had examined him thoroughly and this had been missed.

Young man with medial orbital wall fracture

The same day, we saw two men in the ER who had been assaulted. One stabbed in the eye, the other shot through the cheek, with the eye being the exit wound.  Nearly every face we saw seemed to have some sort of scar.

Several cases of facial trauma

The young man with the stab wounds above had 4 1-0 sutures closing all his lacerations.  1-0 suture is usually used to close very thick tissues, such as the abdominal wall, not delicate structures like eyelids.  I removed them and replaced them with about forty 6-0 and 7-0 sutures.  The young woman above had numerous scars dating back to the earthquake, which split her eyelid in two and left it retracted.

Several post op patients

Her repair involved borrowing skin from her right upper eyelid to lengthen her left upper eyelid, as well as a full thickness resection of her scar and realignment of her eyelid margin.

The cases we did were all difficult, but the cases we couldn’t do were the hardest to deal with. We saw several patients with large growths emanating from various parts of their faces. They had saved money and paid for a CT scan (around $300, average monthly income is $60).  The scans showed invasive tumors filling their eye sockets and often extending into their brains.  Surgery was not an option.  When I’d recommend an oncology consult, the residents would shrug.  They knew that even with a consult, the treatment necessary would not be available in most cases. As one resident said when I asked her to explain to a patient what we were seeing, “tumors don’t go over well here, everyone knows they are going to die.”

Orbital masses

Anyone interested in helping us out, can either donate to CharityVision or contact our office. Every trip we identify a slew of instruments and supplies we need to offer better care.  Any help with attaining these supplies is greatly appreciated.  My retired partner, Dr. Call, and I have committed to having one of us visit every 3 months. The needs are seemingly endless.Share

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Eyebrow proportions from britneybeauty.com

1. First, figure out the best eyebrow shape and color for you, and actively maintain it. Choose a shape you like, but keep it natural. An overly-thin brow makes you look older while very thick or dark brows can dominate your face and take attention from your eyes. Understanding the proportions of a beautiful brow is important. The head of the brow should start in line with the inner corner of the eye and ideally with the outer corner of the nostril (see #1 on Angelina Jolie above).  The peak of the arch should line up with a line drawn from the outer corner of the iris to the corner of the nostril (see #2 above). The end of the brow should fall on a line from the outer corner of the eye to the corner of the nose (see #3 above).

2. Consider reshaping drooping brows with Botox injections. When injected above the brow, it will help to lift the brow into a more youthful-looking position by immobilizing the muscles.

3. Fillers, such as Juvéderm and Radiesse, can be injected and instantly lift the end of a brow that’s begun to sink over time.

4. If you need a dramatic lift, browlift surgery is a permanent fix that can be done endoscopically, which makes it a minimally invasive procedure. During a browlift, the muscles are repositioned to lift the brow into a more natural position. Plus, any sagging excess eyelid skin can be removed as well.

For a few tips on shaping and tweezing the brows properly, click here and here for some excellent articles on Elle.com and here for a video demonstration.  Taking a little time to properly learn to shape your brows can give a whole new look to your eyes.Share

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Earlobe gauge

We’ve all done things to our look that down the road we regret.  A bad haircut or perm, rocking the blue eye shadow a little too hard, countless fashion choices that expired days after they were hot.  But for some choices, a change is more difficult than just changing your wardrobe or letting your hair grow out.  Ear gauges have been trendy for several years now, with some taking it to extremes creating massively stretched out lobes. Many people choose this trend when they are young, in high school or college, only to realize that it is hard to be taken seriously when it’s time to enter the workforce.  Some company dress codes even  preclude employees from wearing large jewelry in their ears, forcing the gauged ears to flop empty throughout the workday.  Many people are now choosing to have plastic surgery to reverse the appearance and return their ears to a more normal appearance.  A recent spot on the TV show “The Drs.” showed a patient undergoing the procedure.

As the video showed, reversing the problem is straight-forward and can be done in the office.  Scarring is minimal and generally improves over the first year.  The ears can be re-pierced after a few months if that is desired.  We perform a similar procedure on earlobes that have been stretched out by heavy earrings and lobes torn through accidentally.  If you have gauges and want to discuss having them reversed, give our office a call at (801)-264-4420.

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Dr. Call performing one of many operations in Haiti

Our arrival was relatively uneventful.  We were delayed a day after tropical storm Isaac blew through the Caribbean and past south Florida.  The ride from the airport was eye-opening for someone who had little experience with the third world.  Throngs of people everywhere among houses reduced to rubble (or in the slow process of being reduced). Trash strewn streets framed arteries of people flowing in all directions or huddled in clotted masses around impromptu markets and street-side restaurants.  The energy was palpable, but felt like it was racing out in all directions, but accomplishing little.

Waiting for clean water in Port-au-Prince

We arrived at the hospital early Tuesday, a single story concrete building with visible cracks and rents in most of the walls.  A large crowd of people was assembled out front.  We pushed our way through the mass, past a metal gate and into a small courtyard ringed in short banana trees with a central awning and concrete half-wall seating.  A small meeting room and a few examination rooms also opened onto the courtyard with the small operating theater near the back of the plaza.  The facilities were Spartan, but adequate.

Young woman with anthrax scarring

We quickly went to work seeing patients, many of whom had traveled some distance.  I was immediately struck by the amazing variety of pathology.  Most every case was far advanced, or what may be considered end-stage in the US.  Tumors that filled eye sockets, horrific scarring from previous anthrax infections, scarred eyelids with eyelashes curled in and abrading now opacified corneas, all seemed commonplace in this unfortunate group of patient.  A parade of children with small and large tumors was brought in. Some thankfully were benign dermoid tumors, scary in appearance but ultimately harmless.  Others were huge and disfiguring causing destruction of the eye or indicating a serious pervasive, likely life-threatening neoplasm.  When a young lady walked in with a simple drooping eyelid, I felt relieved that at least on case would be straight-forward.  I would later retract my enthusiasm.

Teenage girl with large orbital tumor

Once we’d filled our day’s schedule, we headed to the operating room.  The Haitians are very curious when it comes to sterility and behavior in the OR.  They are almost fanatical about certain things, such as not wearing scrubs uncovered outside the OR, while they use the same gown throughout an entire day of surgery.  They often pass instruments back and forth between operating tables (we are operating simultaneously on two patients just a few feet apart) as long as they perceive the instruments haven’t been contaminated, but they are able to effectively reuse many items we would consider disposable, stretching the articles life far past it viable use.

The adventure in third-world surgery comes when the patient is prepped and ready.  As a surgeon, you quickly develop a plan in your mind based on the pattern of disease before you.  A ptosis surgery will require a skin incision, exposure of the levator aponeurosis via dissection through several delicate soft tissue layers and measured advancement of the eyelid muscle tendon to raise the height of the lid.  In an ideal situation you’ll have delicate instruments for the task. In Haiti we had a literal grab bag of old, dull and oversized instruments to choose from.  This turned straight-forward surgery into difficult surgery and difficult surgery into extremely difficult surgery.  After a few cases, you just accept the situation and muscle through, which is easy when you see the joy you bring to patients with no other hope.

Tumor removal in young woman

After 3 days of case after case our time was done.  We packed up, boarded our plane and headed out.  On our drive to the airport we drove through the biggest tent city left from the 2010 earthquake.  USAID tarps held up with old boards random pieces of sheet metal went on for miles.  I was heading back to my house in the mountains with A/C, fresh water and warm beds.  We may have helped a few, but thousands more still need our help.  You can’t leave Haiti without already formulating a return plan in your mind.

Post-op patients

Haitian ophthalmology residents with Dr. Harris and Dr. Call

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Vitamin E: Almonds are packed with vitamin E, which is a powerful anti-oxidant which scavenges free radicals which can cause skin breakdown.  In one study where participants consumed 14mg of vitamin E (about 20 almonds), they had less evidence of UV skin damage after sun exposure.

Omega 3 fatty acids: The omega 3′s are essential fatty acids, meaning you don’t make them on your own and have to get them through the diet.  They are linked to lower triglycerides and have several beneficial effects for the heart.  Flax seeds are packed with omega 3′s. In one skin study, participants that consumed a half teaspoon of flax seed for 6 weeks had more plump and hydrated skin with less redness and irritation.  Salmon is also a great source of omega 3′s.

Lycopene: This free-radical found most commonly in tomatoes can also give extra protection from UV radiation.  Cooking tomatoes will concentrate this nutrient.  Lycopene is also found in watermelon.

Vitamin C: This is a key ingredient in collagen and is found in lots of foods, including citrus fruits and carrots.  Sweet potatoes are an excellent source.  One study showed that consuming 4mg daily over time can reduce the formation of wrinkles by as much as 11%.

Folic acid: Leafy green vegetables are a great source of this nutrient, which is integral to DNA repair.  Studies have shown that those who eat a diet rich in green vegetables including folic acid have half as many skin tumors as those who have diets sparse on these vegetables.

Omega 6 fatty acids: Described as the ultimate moisturizer, omega 6 fatty acids have been shown to reduce scaly, itchy skin and may be of great benefit to people with eczema.  Safflower oil is an excellent source.

Vitamin A: This fat soluble vitamin helps reduce the overproduction of surface skin cells, reducing skin oils and clogged pores.  Carrots are a great source.

Catechin: This anti-oxidant is prominent in hot green tea. It has been shown to have anti-inflammatory and anti-cancer properties.  It has been shown to reduce the effects of sun damage in people drinking 2-6 cups daily.

Flavanols: Dark chocolate is rich in this anti-oxidant shown to reduce the roughness of skin and prevent skin cancer.

A good rule of thumb is to eat a diet high in vegetables, incorporating as many colors as possible.  Avoiding foods with a high glycemic index has also recently been associated with clearer skin.  In addition, dairy has been recently linked to acne and anecdotal evidence has spurred a number of new studies.  Bottom-line, a healthy diet will be evident in a brighter, healthier countenance.

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Pre-op: Prepare for surgery

Patients can make their surgery much smoother by following a few simple rules before surgery.  Beginning 2 weeks before the procedure, they should identify and avoid any medications, supplements or foods that may cause them to bleed more easily.  The list is extensive, but includes aspirin, ibuprofen, naproxen (Aleve), fish oil and vitamin E.  They should consult with their prescribing doctor if they have a history of heart arrhythmia or blood clots to ensure it is safe to stop taking the medication. Patients on coumadin will need around 5 days off the medication to allow safe surgery. They are often “bridged” during this time with an injectable blood thinner, such as Lovenox.  To reduce stress on the day of the procedure, ensure transportation is arranged and ask your doctor if you can fill any post-op medication prescriptions ahead of time. Have a normal meal the night before surgery and remember to not eat after midnight.  You should take your normal medications the day of surgery, with the exception of any diabetic medications while fasting.  These should be taken with a very small amount of water.  Shower and wash your hair the morning of surgery.  This will cut down on skin bacteria lessening the chance of infection. You may not be able to shower for a few days after the procedure and will be glad you did just before surgery.

During Surgery: Relax and let your surgical team work

You’ve searched out and chosen a doctor and surgery center you trust. Let them do their job on the day of surgery. Some patients see a need to second guess a lot of what is going on around them, usually out of anxiety.  Although you should call attention to anything you see as an error, you should also be helpful in getting the team the information they need to perform your surgery well. Relaxing will lower your blood pressure and make administering anesthesia easier and safer.  Don’t hesitate to let them know if you are in pain however, as they will want you as comfortable as possible.

Post-op: Follow directions for a quicker recovery

Your surgery has gone well and your are off to your home to recuperate. Your doctor has given you a list of instructions to follow. This list has been born out of years of experiences with thousands of patients.  Although each patient is different, on average they can expect a similar course and these instructions are aimed at making that course as smooth as possible.  Begin by ensuring you have your post-op ointment and pain pills filled.  Once home, begin immediately applying ice to the eyelids for 20 minutes on and off.  Sit with your head elevated above your heart to reduce dependent swelling.  Avoid any bending over or strenuous activity, no matter how good you feel.  Most broken sutures and open wounds result from people getting back to there normal activities too soon. Apply the ointment at least 4 times daily.  At night, sleep with the head elevated. Day two will greet you with a scary picture in the mirror. Your eyelids will likely be much more swollen and purple than the day prior.  You may even have trouble opening your eyes.  The ointment will be melting and getting in your eyes, making seeing difficult. This is when you are glad you took several days off work and re-upped that Netflix subscription.  Time spent resting and recuperating now will pay off later with fewer complications and a more rapid recovery. Keep up the ice every 20 minutes and avoid rubbing the eyelids.  After 2-3 days, you’ll start noticing gradual reduction of the swelling and a slow color change of the bruising as it fades. This is when the itching will begin to get annoying.  As the stitches are dissolving and breaking down and the skin is healing, severe itching can occur. Resist the urge to scratch and instead treat it with cold compresses.

Follow-up: Let your surgeon monitor your progress

Be sure and follow up with your surgeon within one to two weeks of surgery to ensure healing is on track.  By then you should be noticing great improvements day to day.  Follow up sooner if you experience a complication, such as uncontrollable bleeding, worsening pain or swelling, significant discharge from the wound or any separation of the incisions.

Knowing what to do before surgery and having realistic expectations after surgery will make your experience much more pleasant. Surgery isn’t for the faint of heart, but anyone can have a good outcome with proper preparation.Share

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Image from RealSelf.com, article by Melissa Rudy

Of course there is a flip side: youth who want to look a certain way for a variety of complicated reasons turning to surgery to make it happen.  The psychology of this can’t be generalized, but in many cases, children want to please those around them and view their looks as something they can control and manipulate (spoiler alert: this doesn’t change when we reach adulthood).  Unfortunately, the decision to have surgery has permanent lasting effects and possible complications.  Counseling a patient is hard enough when they are an educated adult.  A teen may not fully understand the risks of surgery.  Parents would need to give their consent, but they also may be blinded by a desire to have their child fit in, or make them happy.  A recent poll of readers on RealSelf.com showed that up to a quarter of parents felt it was okay for children to have nose or ear surgery if they were being bullied.  Around than 10% felt it was okay to have breast reduction or double eyelid surgery (conversion of Asian eyelid to a Western appearing eyelid).  Only about 3% felt breast implants would be appropriate for a child.

I don’t claim to have the answer as to when or if elective cosmetic surgery is appropriate for children.  I do feel it is important to weigh all the possible angles before allowing your child to make such a permanent change to their appearance.Share

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Myth #1: “I have to get a base tan so I won’t burn on my vacation. Many believe they need to achieve a “base tan” early in the spring, usually at a tanning booth, so they won’t get sunburned later.  Some even think this is protective against sunburns and thus skin damage.  Don’t buy into this farce. Any sun or tanning bed exposure that causes a tan is damaging your skin, end of story.  UV rays are still blasting away at your DNA and collagen no matter the color of your skin. Spray tans are no help either. Some believe that these will somehow protect you from a burn or damage.  Not true.

Myth #2: “I only need sunscreen if I’m going to the beach.”  Most people don’t think to put on sunscreen, unless they are expecting to be outside for an extended period of time.  A recent New England Journal of Medicine article showed a man who drove a delivery truck for 28 years. He developed dramatic changes to the left side of his face, which was bombarded by UVA rays, while the right side of his face was protected from the shade.  Check out the difference between the sides in the picture below.

Myth #3: “I’ve got dark skin so I don’t get sunburned.”  Many people born with naturally darker toned skin think to don’t need to protect their skin as they don’t burn as easily.  Whether or not you get a sunburn, the UVA and UVB rays are still bombarding you, causing mutations in your DNA and ruining your skin’s elasticity.  Olive skinned people don’t look any better in their old age than fair skinned people. Very dark skinned people are also at risk for sun damage.  Acral lentiginous melanoma accounts for 50% of melanomas in dark skinned individuals and is often missed as it develops on the palms and soles of the feet. Bob Marley died of this form of melanoma.

Myth #4: “It’s cloudy, so I’ll skip the sunscreen. “  UV rays are still present on cloudy days. If you are going to be outside, apply sunscreen.

Myth #5:  “I wear sunscreen, so I’ll never have skin problems.”  I wish sunscreen was that good. The mistake most of us make is not reapplying it often enough and not realizing that it doesn’t block all UV radiation.  When possible, wearing hats, sunglasses and longer clothing will block out more UV radiation and further reduce your potential skin damage. Sunglasses are especially important to reduce early cataracts and surface damage to the eyes, including unsightly yellow spots on the eyes called pinguecula (see photo).

Pinguecula

Myth #6: “Tanning beds are a safer way to tan.”  And O.J. Simpson is innocent.  The tanning bed industry is constantly working to convince people that tanning beds are safe or even healthful.  Some claim their bulbs emit lower UVB and other say tanning is a great way to get your vitamin D. Both of these claims are misleading.  All tanning beds cause accelerated skin damage.  Multiple studies have shown that people who use tanning beds have a higher rate of melanoma.  And regarding vitamin D, you need about 2-10  minutes a day of sun exposure a day to produce plenty. If you drink milk regularly or take vitamin D supplements you don’t need any extra sun exposure.Share

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The key to Botox/Dysport is putting the right amount in the right place.  That seems intuitive, but results can vary greatly by the technique used and experience of the injector.  Botox is popular because it works and most people who are happy with their Botox treatment get a nice flattening of the lines between the brows, on the forehead and in the crow’s feet.  When improperly placed, brows drop or have a “Spock” appearance, lower eyelids can sag, and the face may look too inanimate to be real.  To get a natural effect, first start with an experienced injector, one that will study your facial expression and target the problem muscles, rather than just injecting in a standard pattern.  Then, expect to be invited back after the first week to ensure the proper result was attained.  Sometimes, I feel I’ve given my patients enough to relax the forehead evenly, but after a week I need to add a few more units to the outer forehead muscles.  This allows me to better map out the face and subsequent injections will be on target.  Where a few get into trouble is wanting to eliminate every facial wrinkle with Botox and convincing someone to inject them.  Your face needs expression, which is an underappreciated part of facial beauty.  An appropriate dose of Botox will allow for this movement and still soften the telltale signs of aging.  If your doctor takes his/her time and follows up, your results should end up exceeding your expectations.

In like fashion, the key to good filler is the right filler, in the right amount, in the right place.  Again, that seems intuitive, but many people get into trouble when they want either the wrong type of filler or too much filler placed.  An experienced injector will have a preference for certain brands and types of fillers in different areas of the face.  This is usually based on their experience and results. It is in your best interest to let the injector direct you on what filler they want to use.  If you have a strong preference, seek out a person who specifically advertises using that brand.  With regard to the amount of filler placed, many people think more is better.  This is where the unnatural appearance is most likely to enter the picture.  Overinflated lips, cheeks and tear troughs are dead giveaways that work has been done.  My advice is start slow and add as necessary. Fillers all come by the vial.  An injector can inject part or all of the vial and save the rest for a few days until the initial swelling has resolved.  This allows a metered approach and can give you a maximum improvement without overdoing it.  The flip side to this comes when patients expect a maximum improvement at a minimal cost.  Often two to three (or more) vials are necessary to get a significant improvement, especially in the smile lines and cheeks.  With one vial retailing for around $500-600, many people aren’t willing to spend that much on a non-permanent procedure.  This is where you need to have a frank discussion with your injector about what result you can expect and whether you’d be better off saving for a surgical procedure or maximizing other less invasive treatments.  Having appropriate expectations is key to your satisfaction.

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