Maggot Therapy

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

When I was a general surgery resident, we had a couple of patients come in with maggots in their wounds--both with venous stasis ulcers on their legs. As "icky" as it was to clean the maggots out of the wounds, it was down right impressive how clean the wounds were (and yes it was my job to do the cleaning). Those maggots sure had done a wonderful job of removing the necrotic tissue and leaving behind healthy granulation tissue.  So for Halloween, how about some bug therapy.

Maggot therapy waxes and wanes in popularity throughout time. Ambroise Pare (1509-1590) is generally given credit for first noting the beneficial effects of maggots in suppurative wounds. Napoleon's famous military surgeon, Baron D. J. Larrey (1766-1842) noted larvae of the blue fly in the wounds of soldiers in Syria during the Egyptian expedition. He noted that the maggots only attacked putrefying substances rather than living tissues and that they promoted their cicatrization. W. W. Keen commented on the presence of maggots in wounds during the Civil War, saying that the maggots were disgusting but did no apparent harm. The first scientific study of the use of maggots was done by Dr. William S. Baer of Baltimore, Maryland. He first mentioned this "viable antiseptic" for the treatment of chronic osteomyelitis in a discussion following an article by Bitting that appeared in 1921. Baer commented on the clean wound of two soldiers with neglected compound femur fractures and abdominal wounds who had lain neglected for 7 days on the battlefields of World War I in 1917. Inspection of the wounds showed that they were infected with thousands of maggots, but had healthy granulation tissue beneath. At that time, the mortality from such wounds with the best medical care was close to 75%, and therefore the maggots made a profound impression. He went on to study maggots in detail.

Maggots, by definition, are fly larvae, just as caterpillars are butterfly or moth larvae. Phaenicia sericata (green blow fly) larvae is the one used in maggot therapy. One-day-old larvae are only about 2 mm in length, and almost transparent. By the time the maggots are 3 or 4 days old, they have grown to about 1 cm (1/2 inch) long.

Maggot Therapy

Maggots may be used intentionally as biological debriding agents. They are an effective alternative to surgical debridement in patients who cannot go to the operating room for medical reasons. It is the larvae of the green blowfly (Phaenicia sericata) that is used. This larvae is sterilized with radiation before being used so that they will not be able to convert from the larvae to the pupae stage. They secrete enzymes that dissolve the necrotic tissue and the biofilm that surrounds bacteria. This forms a nutrient-rich liquid that larvae can feed on. Thirty larvae can consume 1 gram of tissue per day. They are placed on wounds and covered with a semipermeable dressing. The debridement is painless, but the sensate patient can feel the larvae moving. More importantly, maggots help to sterilize wounds, because they consume all bacteria regardless of their resistance to antibiotics (including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus). Maggots have to be replaced every 2 to 3 days. Maggot therapy can be administered on an outpatient basis, provided that visiting nurses are familiar with their use. This is a good technique for painlessly removing necrotic tissue and destroying antibiotic-resistant bacteria in patients who cannot undergo surgical debridement for medical reasons. They work well in infected and gangrenous wounds, with the best results reported in diabetic wounds.

Medical grade larvae are available from Zoobiotic Ltd and Monarch Labs.

HAVE A SAFE 'HAPPY HALLOWEEN'!

References

Maggot Therapy: The Surgical Metamorphosis; Plastic & Reconstructive Surgery. 72(4):567-570, October 1983; Pechter, Edward A. M.D.; Sherman, Ronald A. B.S.

From the Bible to Biosurgery: Lucilia sericata--Plastic Surgeon's Assistant in the 21st Century; Plastic & Reconstructive Surgery. 117(5):1670-1671, April 15, 2006; Whitaker, Iain S. M.A.Cantab., M.R.C.S.; Welck, Matthew M.B.Ch.B.; Whitaker, Michael J. M.A.Cantab.; Conroy, Frank J. M.R.C.S.

Maggot Debridement Therapy; Plastic & Reconstructive Surgery. 120(6):1738-1739, November 2007; Mumcuoglu, Kosta Y. Ph.D.

Clinical Approach to Wounds: Debridement and Wound Bed Preparation Including the Use of Dressings and Wound-Healing Adjuvants; Plastic & Reconstructive Surgery. Current Concepts in Wound Healing. 117(7S) SUPPLEMENT:72S-109S, June 2006 ; Attinger, Christopher E. M.D.; Janis, Jeffrey E. M.D.; Steinberg, John D.P.M.; Schwartz, Jaime M.D.; Al-Attar, Ali M.D.; Couch, Kara M.S., C.R.N.P., C.W.S.

Spider Veins

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Just in time for Halloween--those "scary-looking" spider veins. (photo credit)

It is estimated that up to 50% of women by age 50 will have telangiectatic (spider veins) leg veins. It has been estimated that 10-20% of adults in the United States and Western Europe have varicose veins. The difference between varicose and spider veins is one of size. The tortuous veins greater than 4-5 mm in diameter are referred to as varicose. The veins between 1-4 mm in diameter are referred to as reticular, and the veins less than 1 mm in diameter are referred to as telangiectatia (spider veins). All three are the visible surface manifestations of an underlying venous insufficiency syndrome. Venous insufficiency syndromes allow venous blood to escape from a normal flow path and flow in a retrograde direction into an already congested leg.

"The most common scenario-- a single venous valve fails and creates a high-pressure leak between the deep and superficial systems. High pressure within the superficial system causes local dilatation, which leads to sequential failure (through over-stretching) of other nearby valves in the superficial veins. After a series of valves have failed, the involved veins are no longer capable of directing blood upward and inward. Without functioning valves, venous blood flows in the direction of the pressure gradient: outward and downward into an already congested leg. As increasing numbers of valves fail under the strain, high pressure is communicated into a widening network of dilated superficial veins in a recruitment phenomenon. Over time, large numbers of incompetent superficial veins acquire the typical dilated and tortuous appearance of varicosities. " (photo credit)

Common predisposing factors

• Family history
• Standing for long periods of time
• Pregnancy
• Age

History

• Common symptoms that should be elicited include leg heaviness, exercise intolerance, pain or tenderness along the course of a vein, pruritus, burning sensations, restless legs, night cramps, edema, skin changes, and paresthesias.
• Common symptoms of telangiectasia include burning, swelling, throbbing, cramping, and leg fatigue. Pain associated with larger varicose veins usually is a dull ache that is worse after prolonged standing
• Pain caused by venous insufficiency is often improved by walking or by elevating the legs in contrast to the pain of arterial insufficiency, which is worse with ambulation and elevation.

Physical:

Veins and their connections become gradually better defined through inspection, palpation, percussion, and hand-held Doppler examination to form a venous map that later guides treatment. The courses of all the dilated veins that are identified may be marked along the leg with a pen and later transcribed into the medical record as a map of all known areas of superficial reflux.

• The Perthes maneuver is a traditional technique intended to distinguish antegrade flow from retrograde flow in superficial varices. Antegrade flow in a variceal system indicates that the system is a bypass pathway around deep venous obstruction. This is critically important because, if deep veins are not patent, superficial varices are an important pathway for venous return and must not be sclerosed or surgically removed.
• The Trendelenburg test can often be used to distinguish patients with superficial venous reflux from those with incompetent deep venous valves.
• Doppler examination is an adjunct to the physical examination that can directly show whether flow in a suspect vein is antegrade, retrograde, or to-and-fro.

TREATMENT

SCLEROTHERAPY
Sclerotherapy is the introduction of a foreign substance into the lumen of the vein to cause thrombosis and subsequent fibrosis.

Chemical Irritants produce direct destruction of the endothelial cells.

• Glycerin--for use in veins less than 1 mm in diameter
• Polyiodinated Iodine

Hypertonic solutions produce dehydration of endothelial cells through osmosis, resulting in endothelial destruction.

• Hypertonic-saline 11.7% --for use in veins less than 1 mm in diameter
• Hypertonic-glucose

Detergent sclerosants produce endothelial damage through interference with the cell's surface lipids.

• Sodium morrhuate
• Sodium tetradecyl sulfate, 0.25% used in veins less than 1 mm in diameter; 0.25-0.5% used in 1-4 mm veins; and 1-3% used in veins 4-10 mm in diameter
• Ethanolamine oleate
• Polidocanol foam, 0.5 % used in veins less than 1 mm; 0.5-1% used in veins 1-4 mm; and 2-5% used in veins 4-10 mm in diameter

Postsclerosis compression is important for multiple reasons, one of which is to support the untreated vessels while the sclerosed vessels heal/scar. (photo credit)

MINIPHLEBECTOMYMiniphlebectomy or ambulatory phlebectomy allows removal of short segments of varicose and reticular veins through tiny incisions using special hooks developed for the purpose. This procedure is extremely useful for the treatment of residual clusters after saphenectomy and for removal of nontruncal tributaries when the saphenous vein is competent.

TRANSCULTANEOUS LASER AND INTERMITTANT PULSED LIGHT (IPL) have proven effective for the tiniest surface vessels (eg, those found on the face), but this modality is not generally useful as primary therapy for treatment of spider veins of the lower extremity. For most patients, the laser pulses are significantly more painful than the 30-gauge needles used for microsclerotherapy. Most spider veins of the legs have associated feeding vessels that must be treated by some other means before the tiny surface vessels are amenable to laser or IPL treatment.

LASE (Laser assisted Saphenous Endoablation)
The procedure was pioneered in 1999 by Dr. Robert Min and Dr. Luis Navarro in conjunction with Diomed. The technique continues to be refined and enhanced today reflecting Diomed’s ongoing commitment to the science and practice of vein management. EVLT® is a minimally invasive, clinically proven alternative to surgical vein stripping that effectively and safely treats varicose veins using a diode laser fiber to occlude the vein. (photo credit)

LIGATION
Some problems, such as large varicose veins, may call for ligation, a procedure in which the connections between the damaged veins and the normal vein systems are interrupted. Saphenectomy with saphenofemoral ligation is a traditional approach that is most often performed using an internal stripping tool and an invagination technique.

Complications:

• Complications of varicose disease include venous ulcers, variceal bleeding, and venous thromboembolism.

• Potential complications of treatment include anaphylaxis, changes of pigmentation, ulcerations, paresthesias, arterial injury, and venous thromboembolism.

PREVENTION --Activity is a strong protective factor against venous stasis. So I would encourage all of you to move--walk, dance, fidget. Be active.

• Pregnant patients and those with a strong family history of varicose disease may prevent, delay, or ameliorate the problem by wearing 30-40 mm Hg gradient compression hose whenever standing.

• Constant use of compression hose can prevent the worsening of existing varicose disease that cannot be treated immediately

References
Varicose Veins and Spider Veins--Women's Health.gov
Varicose Veins and Spider Veins by Craig Feied, MD--eMedicine Article
No More "Spider Veins" by Michel P Goldman, MD--Plastic Surgery Products Newsletter, October 2007
Varicose Veins--Mayo Clinic
Spider Veins (Sclerotherapy),Diminishing Unsightly 'Spider Veins'--American Society of Plastic Surgeons
Minimally Invasive Venous Intervention Procedure (OR-Live)--Morristown Memorial Hospital (requires media player, 1 hour program)
Treatment of Varicose Veins through Laser Surgery (OR-Live)--Nebraska Medical Center (requires media player, 1 hour program)
Site with good before and after photos--Veintec Varicose Vein Clinic

Glomus Tumor

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

A glomus tumor is a rare benign tumor of the hand. It constitutes 1–5% of the soft-tissue tumors in the hand. It arises from the glomus body which is a neuromyoarterial apparatus described by P. Masson in 1924. The normal glomus body is an arteriovenous shunt that is composed of an afferent arteriole, an anastomotic vessel (Sucquet-Hoyer canal), a collecting vein, and a capsular portion. It resides in the stratum reticulum of the skin. There are large numbers in the subungual region and in the distal pad of the digits. The glomus body is a controlled arteriovenous anastomosis or shunt between the terminal vessels thought to be important in regulating peripheral blood flow in the digits, which secondarily controls peripheral blood pressure and body temperature. (photo credit)

Glomus tumors affect women two to three times more often than men. Most are in the 30-50 year age group. Most occur in the subungual area (approximately 50%), but can occur on the finger tip pulp, the palm, wrist, forearm and foot. Glomus tumor can occur near the tip of the spine, where it may arise from the glomus coccygeum. Glomus tumors have also been described in locations where the glomus body does not normally occur. These unusual sites include the patella, bone, chest wall, eyelid, colon, rectum, and cervix. Over 75% of glomus tumors occur in the hand.

Symptoms usually consist of a triad

• severe paroxysmal pain--the pain can be excruciating and is described as a burning or bursting
• localized tenderness
• extreme cold sensitivity

Physical exam reveals a blue-pink tender mass that can often be seen through the nail plate or skin. When the mass is growing beneath the nailbed (subungual), it can displace the nailbed dorsally. (photo credit) When the lesion is beneath the nail matrix, it can produce a longitudinal ridging of the nail plate. Placing the involved digit or extremity in ice water will reproduce the pain within 60 seconds. Typically, the mass is usually less than 7 mm in diameter, so can be very difficult to palpate even when not beneath the nail. There are two clinical findings described, particularly in relation to the painful subungual solitary glomus tumors. They are the Hildreth's sign and Love's test. Hildreth's sign is disappearance of pain after application of a tourniquet proximally on the arm. Love's test consists of eliciting pain by applying pressure to a precise area with the tip of a pencil. Routine laboratory studies have no role in diagnosis of glomus tumor.

X-rays of the finger may show bone erosion, ranging from a small concave defect to a sharply defined radiolucent lesion seen in the region of the tuft of the phalanx. There is often a thin sclerotic margin about the defect as a secondary reaction to the tumor pressure. Standard magnetic resonance imaging (MRI) can be used to detect glomus tumors. (photo credit)

The tumor consist of a highly organized, well-encapsulated mass consisting of glomus cells, curled blood vessels, and a large number of nerves within or adjacent to the lesion. This explains the great sensitivity of the glomus tumor.

Treatment is surgical. Surgical approach will vary depending on the location of the tumor. The glomus tumor is always well encapsulated and can usually be "shelled out" with little or no difficulty. When excision is complete, the prognosis is excellent for full recovery with no recurrence.

References

Glomus Tumor by Henry DeGroot, III MD--bonetumor.org

Glomus Tumor at Wheeless Textbook of Orthopedics

Subungual glomus tumor by Dr. K.-- MSKcases

Glomus Tumor of the Finger Tip and MRI Appearance by David H Kim, MD--Iowa Orthop J. 1999; 19: 136–138.

Two cases of subungual glomus tumor; Murthy PS, Rajagopal R, Kar PK, Grover S; Indian J Dermatol Venereol Leprol 2006;72:47-9

Glomus Tumor by Michael B Reynolds, MD--eMedicine Article

SurgeXperiences 107 is Up!

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

The bi-weekly surgery carnival is up over at Vitum Medicinus. The author is a "23-year-old in his second preclinical year at a Canadian medical school." There are some interesting links. (photo credit)

Humane Society Day Planner

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

Our local humane society (Pulaski County Humane Society) began publishing a Day Planner in 2005. It has turned into a very good fund raiser for them. Last night was the debute of the 2008 seen here. I ordered several that first year to give as Christmas presents. They were such a big hit the first year, I've had to keep doing it.

The first year (2005) we put a picture of my first "true" pet--Columbo-- in the calendar. He had died in November 2002 at age 9 yrs from a strange abdominal cancer. Despite both human and veterinarian pathologist looking at the slides, no diagnosis could be given other than a malignancy. He was an extremely cool dog!

He would carry 5 gallon buckets around the yard, roll the bucket,

and toss it in the air with his head.

He loved to catch soccer balls as they bounced off the roof.

The next year (2006) we put Ladybug's photo in. I posted about her here. She died in May 2002 from osteosarcoma of her left maxilla. The "thing" in her mouth is a rolled up raw hide, not a cigar. She was quite the charmer!

This past year (2007) we had Girlfriend's photo in the calendar. We lost her this year to a canine hemangiosarcoma. I still can not make myself change my profile to say I only have one dog rather than two. I will do it someday, but not today. I still miss her too much. I keep having to correct myself when I tell someone I'm "off to walk my dogs".

This year (for 2008) we had two sets of photos put in. One for our neighbors who lost their beloved Maggie, a border collie, to old age. And the other for my brother and his wife (who live in South Carolina)--someone had poisoned several of their dogs by adding anti-freeze to some food and giving it to the dogs. In the calendar, the photos are placed on two memorial pages (didn't photograph well for me to show you).

Next year my husband says is Rusty's year. I've got to work on getting a really good picture of him. He too is a character! Check out this video of him "playing" basketball.

Striae (Stretch Marks)

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

I am often asked "What can I do to get rid of my stretch marks?" The short (honest) answer is nothing. Stretch marks are scars. The longer answer is addressed here---causes and ways to improve their appearance. 

Striae distensae (stretch mark) is a common skin condition. It rarely causes any significant medical problem. However, striae can be of significant emotional distress to those affected. They represent linear dermal scars accompanied by epidermal atrophy. (photo credit) 

Stretch marks affect skin that is subjected to continuous and progressive stretching. Common predisposing circumstances for the development of stretch marks include: those which involve a physical stretching of the skin, such as rapid weight gain or adolescent growth spurts, and others that involve hormonal changes, such as chronic steroid medication use or Cushing syndrome (increased adrenal cortical activity). Genetic factors could certainly play a role, although this is not fully understood.[I have never seen stretch marks occur from augmentation mammoplasty or soft tissue expanders, nor are they ever listed as a possible complication of those surgeries.] 

Regardless of their causes, all stretch marks follow a natural course of progression. An early sign of stretch marks developing is when an area of skin becomes flattened and thin with a pink color. The area may occasionally be itchy. Soon reddish or purplish lines develop (striae rubra). Over time these lighten to become whitish or flesh-colored and much less conspicuous. Stretch marks are usually several centimeters long and 1-10 mm wide. Those caused by corticosteroid use or Cushing's syndrome are often larger and wider and may involve other regions, including the face. 

How are they treated?

There are many treatments available, ranging from therapy applied to the skin, laser therapy, and even more invasive surgical methods. Unfortunately, stretch marks remain a tricky problem to target, in which no established treatment exists. Recent studies have evaluated laser treatment on stretch marks of various ages, topical 0.1% tretinoin cream applied to early clinically active stretch marks, and treatment of mature stretch marks with two different topical regimens (including glycolic acid, L-ascorbic acid, zinc sulfate, and tyrosine vs glycolic acid, and tretinoin emollient cream). Treatment with laser and treatment with glycolic acid in combination with 0.05% tretinoin emollient cream appeared to increase the elastic content in the treated lesions, improving the appearance of the striae. (Please, note none of these treatments remove the stretch mark. They only improve the appearance of the stretch mark.) In particular, clinical improvement in the laser treated group continued for 6 months or more after treatment.

The left photo is prior to treatment with tretinoin 0.1% cream, the right is after 8 weeks of treatment (same person). I don't really appreciate the improvement, do you? photo credit

The only way to truly remove (or get rid of) a stretch mark is to surgically excise it. If your stretch marks happen to "sit" in the area of your central lower abdomen, then you may be able to have yours removed by an abdominoplasty. Most of us aren't that fortunate. Many of us have them on our hips or outer thighs from puberty. If you are a teenager, the stretch marks you have now that are in that bright pink or purple stage will fade. That alone will make them less visible. 

Be careful if someone promises to completely get rid of or erase your stretch marks. There is no proven way to do so at this time.

References
Striae Distensae by Samer Alaiti, MD--eMedicine article
Stretch marks (striae)--DermNet NZ
Stretch Marks by Patrice Hyde, MD--Kid's Health article
Stretch Marks--Virtual Medical Centre
Photo Gallery of Stretch Marks
Derm Atlas--Stretch Marks

Poststernotomy Mediastinitis and Repair

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

In the United States, mediastinitis most commonly occurs in the postoperatively. It occurs in 1-2% of patients who have a sternotomy. Most of these patients are cardiac surgery patients (more than 300,000 cases per year in the US). Most of these are coronary bypass patients rather than heart valve or transplant patients. Some other causes of mediastinitis, other than postoperative, include 1) esophageal perforation; 2) trauma, especially blunt trauma to the chest or abdomen; 3) tracheobronchial perforation, due to either penetrating or blunt trauma or instrumentation during bronchoscopy; 4) descending infection following surgery of the head and neck, great vessels, or vertebrae; 5) progressive odontogenic infection (Ludwig angina); 6) mediastinal extension of lung infection; and 7) chronic fibrosing mediastinitis due to granulomatous infections. (photo credit)

Mediastinitis is a life-threatening condition with an extremely high mortality rate if recognized late or treated improperly. Although small in proportional terms (one out of one hundred post-sternotomy), the actual number of patients affected by mediastinitis is substantial (1% of 300,000 equals 3000). This significantly increases mortality and cost.

Even though poststernotomy mediastinits is considered by the Department of Health and Human Services as a "never event" it will still occur. Hopefully, it will decrease to a much smaller (though I doubt ever be a "never") in number event. Prevention guidelines—The CDC surgical site infection prevention guidelines are backed by evidence based medicine. 

Risk factors for the development of mediastinitis postoperatively include the following:

• Bilateral internal mammary artery grafts
• Diabetes mellitus
• Emergency surgery
• External cardiac compression (conventional cardiopulmonary resuscitation)
• Obesity (>20% of ideal body weight)
• Postoperative shock, especially when multiple blood transfusions are required
• Prolonged bypass and operating room time
• Reoperation and/or Reexploration following initial surgery (check out Grunt Doc's post)
• Sternal wound dehiscence
• Surgical technical factors (eg, excessive use of electrocautery, bone wax, paramedian sternotomy

TREATMENT
Medical

Most patients have already received prophylactic antibiotics, usually a first-generation cephalosporin. Very broad and deep antibiotic coverage that includes Pseudomonas species (20% are gram negative) and methicillin-resistant S aureus (20% are MRSA) is needed. Culture results should then guide antibiotic use as multiple regimens are available for use with patients who have mediastinitis. Therapy is usually prolonged, ranging from weeks to months (4-6 weeks of therapy is adequate for most patients). Nutritional support is often necessary. This may be enteral or hyperalimentation.

Surgical options for mediastinitis after cardiac surgery
Effective treatment for simple sternal dehiscence without infection is rewiring the sternum. This usually yields reasonable long-term results. Cultures should be taken to exclude active infection in the cases of sternal dehiscence.

Failure to adequately debride and sterilize the mediastinum during the first reoperation is the most common cause of repeat postoperative mediastinitis. Options for mediastinitis after cardiac surgery are immediate closure after sternal debridement, delayed closure after sternal debridement, and sternal irrigation after sternal debridement. Each has its advantages and disadvantages. The best strategy for accomplishing this depends on the duration of the infection, the condition of the mediastinal structures, and the experience of the surgeon. Below is a diagram of the main pathways for treatment selection as per the presenting wound as per Dr. Norman Schulman (reference 3).

Most surgeons prefer to leave the wound open for subsequent debridement efforts after initial sternal reexploration. In this case, the wound is packed daily until it appears clean with adequate granulation tissue. At this point, muscle flap closure is achieved. The workhorse flap is the unipedicled pectoralis major muscle flap. It is based on its primary blood supply from the acromioclavicular axis. By detaching the muscle from its sternal, rib, humeral, and medial clavicular attachments and separating it from the clavicular head of the deltoid, it can usually be extended to the level of the xiphoid. Back cutting the superior medial segment of the pectoralis muscle for a distance of 4 to 6 cm maintains its blood supply and permits it to be tucked into an upper manubrial dead space. Distal closure at the level of or below the xiphoid is accomplished by approximating the upper medial ends of the rectus sheath with large no. 1 sutures. (photo credit)

Although many closures are accomplished with a single pedicled pectoralis flaps both muscles may be used if necessary on their respective pedicles to provide extensive coverage for the heart and the sternal defect and particularly exposed grafts. Many bypass patients have had the left and on occasion the right internal mammary arteries taken, thus limiting the use of “turnover” pectoralis flaps, which rely on perforators from these arteries. The rectus muscle is very hardy and can provide excellent coverage of sternal defects, especially those involving the lower sternal areas.

Recently, vacuum-assisted closure has been used alone or in conjunction with muscle flap closure for mediastinitis in an attempt to decrease the incidence of this bleeding.

The lack of a bony anterior sternal wall may be unacceptable to some patients and has prompted some surgeons to attempt sternum-sparing procedures, even in more advanced cases. This is often a difficult decision, requiring excellent surgical judgment. Advanced cases of sternal osteomyelitis are extremely difficult to cure, and most patients with muscle or omental flaps do very well from a functional standpoint.

Vacuum-Assisted Closure Photo credit.

Vacuum assisted closure (also called vacuum therapy, vacuum sealing or topical negative pressure therapy) is a sophisticated development of a standard surgical procedure, the use of vacuum assisted drainage to remove blood or serous fluid from a wound or operation site. A piece of foam with an open-cell structure is introduced into the wound and a wound drain with lateral perforations is laid on top of it. The entire area is then covered with a transparent adhesive membrane, which is firmly secured to the healthy skin around the wound margin. When the exposed end of the drain tube is connected to a vacuum source, fluid is drawn from the wound through the foam into a reservoir for subsequent disposal.

The plastic membrane prevents the ingress of air and allows a partial vacuum to form within the wound, reducing its volume and facilitating the removal of fluid. The foam ensures that the entire surface area of the wound is uniformly exposed to this negative pressure effect, prevents occlusion of the perforations in the drain by contact with the base or edges of the wound, and eliminates the theoretical possibility of localised areas of high pressure and resultant tissue necrosis. 

References

Part II, Department of Health and Human Services Centers for Medicare & Medicaid Services ; 42 CFR Parts 411, 412, 413, and 489 Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule --surgical infections

Mediastinitis by Dale K Mueller, MD--eMedicine article

Sternal Wound Reconstruction: 252 Consecutive Cases. The Lenox Hill Experience; Plastic & Reconstructive Surgery. 114(1):44-48, July 2004; Schulman, Norman H. M.D.; Subramanian, Valavanur M.D.

Chest Reconstruction, Sternal Dehiscence by Sanjay K Sharma, MD--eMedicine article
Bipedicle Muscle Flaps in Sternal Wound Repair; Plastic & Reconstructive Surgery. 101(2):356-360, February 1998; Solomon, Mark P. M.D.; Granick, Mark S. M.D.

Use of the Omentum in the Management of Sternal Wound Infection after Cardiac Transplantation; Plastic & Reconstructive Surgery. 95(4):697-702, April 1995; Wornom, Isaac L. III M.D.; Maragh, Hallene M.D.; Pozez, Andrea M.D.; Guerraty, Albert J. M.D.

Mechanisms Governing the Effects of Vacuum-Assisted Closure in Cardiac Surgery; Plastic & Reconstructive Surgery. 120(5):1266-1275, October 2007; Malmsjo, Malin M.D., Ph.D.; Ingemansson, Richard M.D., Ph.D.; Sjogren, Johan M.D., Ph.D.

An introduction to the use of vacuum assisted closure by Steve Thomas, PhD--World Wide Wounds

Over the Jumps Carousel

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Arkansas is lucky to have a very unique carousel--"Over the Jumps". It is one of only four "over the jumps" carousels made by Herschell-Spillman in the 1920's. It is the only one left in working condition. Sixteen years ago a group of Arkansans called Friends of the Carousel formed to save and restore the horses, scenery panels, and machinery to their original splendor. Yesterday, the carousel reopened at its new home, the Little Rock Zoo. It is a carousel that many of us remember riding as children when it was located at the War Memorial Park. Now I (and many others) will be heading to the zoo to ride again. (photo credit) 

History of the Carousel

The heyday of carousels in the United States was from 1887 to 1935. It is estimated that approximately 8,000 were produced during this time, with less than 150 surviving today. Many of those have not been restored. The Over the Jumps, (the Arkansas Carousel), is even rarer because of its undulating track. The track goes up and down rather than the horses so it is similar to a roller coaster. It was constructed in 1924 as a traveling carousel by the Herschell-Spillman Engineering Corporation of North Tonawanda, New York.

The Arkansas Carousel made its first appearance at the 1924 Arkansas State Fair as part of a traveling circuit of amusement rides. Tom Fuzzell, a Little Rock resident bought it in 1942 and housed it in a shelter constructed from one of the original state fair buildings. The purchase saved the ride from destruction and it continued to entertain Arkansans and visitors alike. It was also placed on the National Register of Historic Places as being of state significance in 1989. (Just recently it was added to the Register because of having national importance.) In 1991 owners Mokie Shotes and Doc O'Kelley decided to sell it.
At the time, there was no guarantee the priceless amusement piece would stay together, much less in The Natural State. Little Rock and Arkansas were in real danger of losing it to out-of-state interests, including some as far away as Great Britain. Then Little Rock resident Marlena Grunewald and at the time Senator Mike Kinard, acting separately, decided something had to be done to save the Little Rock landmark. The two eventually joined forces and formed the Friends of the Carousel group, which collected enough donations to make a down payment, keeping it off the auction block. (photo credit)

The initial plan was to restore the ponies, four chariots, and 24 large wooden wheels by just touching up the existing paint. Once the work began, however, it developed into much more as 40 layers of paint were discovered; it became a conservation project. There are 40 ponies, two of which were added at a later date and are not a part of the original carousel, though they were manufactured by the same company. These two, Smarty Jones and Ginger, will be restored at a later date. Smarty is named after the famous thoroughbred and was adopted by the real Smarty’s owners, Chappy and Pat Chapman. Ginger is named in honor of Ginger Murry of Murry's Dinner Playhouse in Little Rock. All the original animals have one of two poses -- heads up or heads down -- and are either an inside or an outside horse. The exterior ponies are more ornately carved and bejeweled, while the interior ones are less decorated but are slightly larger in size. The majority of the restoration work on the horses and chariots has been done by well-known conservator Rick Parker of Gentry, Arkansas. The large wooden wheels were redone by an Amish wheelwright of Bird-in-Hand, Pennsylvania.

FOC Chairman David Martinous of Little Rock estimates the total restoration cost including the mechanicals, to be around $1 million dollars. According to Little Rock Deputy City Attorney Cindy Dawson, who is a FOC board member and serves as legal counsel to the zoo's board of governors, "It has been expensive to go the original restoration route, for sure. It would have been cheaper to have done the 'dip and strip' and paint route, but the decision to restore the original was made by the founding members of the group so the subsequent members have continued on the same path."

When completed, Over the Jumps will be the focal point of a new entry complex at the Little Rock Zoo. The entrance will have an elegant Gay '90s feel with a gift shop, an old-fashioned ice cream parlor, visitor services, formal gardens, and a replica of "Laughing Sally," a coin-operated fortune teller long associated with the carousel when it was at Little Rock's War Memorial Park. Zoo Director Mike Blakely says plans call for the carousel to be open during evening football games at War Memorial Stadium.

Needless to say, all of those of us who enjoyed this classic as a child are eagerly awaiting the unveiling of the final results. Blakely estimates the ceremony to be in May but with a great deal of luck and good weather, it might be April. In honor of this momentous occasion, the Clinton Presidential Center and Park in downtown Little Rock will have a temporary exhibit of the restored horses April 8-30 entitled "Over the Jumps: The Arkansas Carousel." No matter when the grand unveiling of the totally refurbished antiquity takes place, I'll hazard a guess there will be quite a few adults riding the Arkansas Carousel that day -- and for many days to come.

KATV Video on history of the carousel

Dressings for Acute and Chronic Wounds

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

A strong consensus was reached for use of the following combinations: for chronic wounds, (1) debridement stage, hydrogels; (2) granulation stage, foam and low-adherence dressings; and (3) epithelialization stage, hydrocolloid and low-adherence dressings; and for the epithelialization stage of acute wounds, low-adherence dressings," the review authors write. "For specific situations, the following dressings were favored: for fragile skin, low-adherence dressings; for hemorrhagic wounds, alginates; and for malodorous wounds, activated charcoal."

Chronic wounds were defined as those expected to take more than 4 to 6 weeks to heal because of 1 or more factors delaying healing, including venous leg ulcers, pressure ulcers, diabetic foot ulcers, extended burns, and amputation wounds. Acute wounds were defined as those expected to heal in the expected time frame, with no local or general factor delaying healing. These included burns, split-skin donor grafts, skin graft donor site, sacrococcygeal cysts, bites, frostbites, deep dermabrasions, and postoperative-guided tissue regeneration. Summary from the MedScape article by Dr. Laurie Barclay. 

So what are these dressings? What is a hydrogel? or an alginate?

HYDROGELS

Hydrogel dressings are composed mainly of water in a complex network that keep the cross-linked polymer gels intact. The water is released to provide and maintain a moist wound environment. By increasing moisture content, hydrogels have the ability to help cleanse and debride necrotic tissue. Hydrogels are non-adherent and can be removed without trauma to the wound. Hydrogel dressings are not very absorptive, and therefore are not the appropriate choice for moderate to highly exudating wounds. Hydrogel dressings often require secondary dressings for this reason. Hydrogel dressings can be shaped into gauze, sheets, or filler material.

• Tegaderm Hydrogel Wound Filler (3M)
• Intrasite Gel (Smith & Nephew)
• VIGILON Primary Wound Dressing (Bard Medical)
• FlexiGel Strands Absorbent Wound Dressing (Smith and Nephew)--photo credit

SYNTHETIC FOAM DRESSINGS

These dressings were designed to absorb large amounts of exudates and to maintain a moist wound environment. They are not as useful as alginates or hydrocolloids for debridement. They should not be used on low or non-exudating wounds as they will cause dryness and scabbing.

• Allevyn (Smith & Nephew) (photo)
• Lyofoam (Convatec)
• Tegaderm Foam Dressing (3M)

HYDROCOLLOID DRESSINGS

Hydrocolloids are sterile wound dressings, which consist of a hypoallergenic, hydrocolloid adhesive with an outer clear adhesive cover film impermeable to liquids, bacteria and viruses. The inner layer of hydrocolloid adhesive rapidly absorbs exudate. The breathable outer film layer provides for a high rate of moisture vapor transmission. Together, these features ensure an optimal moist wound environment, minimize the chance for damage to healthy skin surrounding the wound and provide extended wear for up to seven days. (photo credit)

• DuoDERM (Convatec)
• Tegaderm Hydrocolloid Dressing (3M), regular and thin

LOW ADHERENCE DRESSINGS

The use of low or non-adherence dressing materials will minimize disruption of healthy granulation tissue and re-epithelialized surfaces.

• Jelonet Paraffin Gauze Dressing (Smith & Nephew) is a low-adherent tulle dressing that allows the wound to drain freely into an absorbent secondary dressing.
• Tegaderm Non-Adherent Contact Layer is a woven nylon fabric with sealed edges that is a lint-free, non-adherent, non-toxic, non-irritating, and hypoallergenic material. It can be left on the wound for up to 7 days. This contact layer can be used under gauze or other absorbent dressings. It will allow exudates to pass through to an absorbent outer barrier. The non-adherence of this material will minimize disruption of healthy granulation tissue and re-epithelialized surfaces. (photo credit)
• Paranet "Vernaid" Sterile Paraffin Gauze Dressing BP

ALGINATE DRESSINGS

These dressings are sterile, highly conformable, and absorbent primary wound dressings for use on moderately to heavily exudating wounds. They are composed of calcium alginate which is a seaweed component. When the dressing is in contact with wound, the calcium in the dressing is exchanged with sodium from the wound fluid and this turns dressing into a gel that maintains a moist wound environment. It is a good dressing for exudating wounds and helps in debridement of sloughing wounds. It should not be used on low exudating wounds as this will cause dryness and scabbing. This dressing should be changed daily. (photo credit)

• Kaltostat (Convatec)
• Sorbasan (Bertek Pharm)
• Tegaderm Alginate High Integrity Dressings (3M)
• Tegaderm High Gelling Alginate Dressing (3M)

The activated charcoal products are for stoma bags to decrease or elimate the odor from the collected urine or feces. The article at DermNet NZ on skin problems from stomas is very well written.

References
Dressings for Acute and Chronic Wounds--A Systematic Review; Arch Dermatol. 2007;143:1297-1304; Olivier Chosidow, MD & others (can access online if AMA member)
Consensus Statement Describes Dressings for Acute and Chronic Wound Management--MedScape article by Laurie Barclay, MD
Wound Dressings--Family Practice Notebook
Synthetic wound dressings at DermNet NZ
Skin problems from stomas at DermNet NZ

SurgeXperience 107--call for submissions

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Vitum Medicinus is hosting SurgeXperiences 107 on October 28, 2007. Submissions will be accepted via a Blog Carnival. Click here to submit your blog post. Please submit your surgery related posts (surgeon, nurse, patient, etc viewpoints welcome). It is meant for learning and sharing. (photo credit) SurgeXperience home can be found here.

More Quilts--QOV and Baby

This past week I mailed off two more QOV quilt tops to someone who will do the actual quilting. The first one pictured is a square-in-a-square pattern. The quilt top size is 50" X 70".

A close up of some of the squares showing the fish.

This next QOV quilt top is a churn dash or shoo fly pattern.
It is also 50" X 70".

A close up of some of the blocks.

This next quilt top is what I worked on today. I had a left over "shoo fly" block, so I used it in a medallion type setting. To me it almost has an Amish feel. This top is 38" X 38" and will be quilted by me and given to someone for a baby (or grandbaby).

Focal Dystonia of the Hand

 Updated 3/2017-- photos/video and all links (except to my own posts) removed as many no longer active.

Earlier this week I read an article in Reader's Digest (November 2007 Issue) on Leon Fleisher and his focal dystonia of his right hand. The article is written by Oliver Sacks, MD and is a exert from his book "Musicophilia: Tales of Music and the Brain". I wanted to review what I knew about focal dystonia and ended up learning much. I would like to try to share this with you. Enjoy this "Ravel Piano Concerto for the Left Hand 1/2" played by Leon Fleisher (video).

The term dystonia collectively refers to a heterogeneous group of movement disorders characterized by sustained involuntary muscle contractions that result from co-contracting antagonistic muscles and overflow into extraneous muscles. Focal dystonias are adult-onset forms that affect a specific area of the body, ie hand, neck, vocal cords. Most focal dystonias are primary. By primary it is meant that the dystonia is the only neurological symptom. 

Focal hand and limb dystonia usually begins as a painless loss of muscular control in highly practiced movements. A genetic predisposition is thought to occur in less than 5% of all cases of focal dystonia. There are many professions that require repeated and intricate hand movements. However, focal hand dystonia is more common in musicians than any other group of professionals, including dentists, surgeons, and writers. This disorder is often referred to in medical literature as occupational cramps (ie, “violinist’s cramp”, “pianist’s cramp”, "writer's cramp"). (photo credit)

Cause
There is no one isolated cause of hand and limb dystonia. A variety of pathological conditions may lead to similar symptoms. As a child develops, he/she learns many different movements (such as walking, writing, or playing an instrument) that are stored in the brain as motor programs. Instances of hand dystonia that are highly task-specific have been described as a “computer virus” or “hard drive crash” in the sensory motor programs that are essential for playing music. However, additional factors, such as a genetic predisposition, are likely to play a significant role in the development of such a sensory-motor dysfunction. Why this “computer virus” cannot be easily overcome by establishing a new and improved sensory-movement pattern remains an important question for researchers. 

Symptoms
Most affected persons describe symptoms in terms of their occupation terms. A musician may notice

• Subtle loss of control in fast passages
• Lack of precision
• Curling of fingers
• Fingers “sticking” to keys
• Involuntary flexion of bowing thumb in strings

A writer may notice:

• Deterioration in neatness or speed of writing or just clumsiness
• A cramp or aching in the hand on writing
• May report that the hand freezes up on attempting to write
• Difficulty in moving the pen across the page

A tremor may or may not be associated with the spasms. In most cases, the dystonia is present only in the context of specific tasks (and may be very specific to one instrument--a clarinet but not a saxophone). The dystonia may appear extremely sensitive to sensory input: a pianist may experience symptoms while playing on ivory keys but not while playing on plastic keys. Sometimes the modification of posture and even facial expressions may affect dystonic spasms in the hand. 

Physical Exam

Inspection

No special examinations are described for focal dystonia other than inspect the patient performing his task.

• The pen commonly is held very tightly, with an exaggeration of the normal semiflexed posture of thumb, index and other fingers, and with hyperextension of the distal interphalangeal joint of the index finger. Occasionally, the hand suddenly stops and the paper is perforated, or it might dart across the page with a sudden jerk. The script produced is usually abnormal. Tremor is a common finding in all forms of writer’s cramp but it is usually not severe. (photo credit)
• Examination of the musician while playing reveals non-physiologic posture and gestures in most of the patients. Sometimes it is possible to identify involuntary dysfunction such as flexion, curling in one or two fingers, or involuntary extension of the “sticking fingers”. These may be difficult to detect, even with slow motion video.

The remainder of physical examination is often normal, but subtle findings can be noted in some patients: dystonic postures of the affected limb when the patients sit or walk, or loss of arm swing of the affected side during the gait. 

 

Palpation

There is minimal unilateral increase in muscle tone in some patients. There are no other abnormal findings. 

Quantification

The Fahn-Marsden scale was designed to quantify generalized or focal dystonia and can be found here. 

Electromyography

Electromyography studies show prolonged duration of muscle bursts with superimposed shorter, repeated bursts of activity. The pattern is of complete lack of selectivity for individual muscles with overflow of contraction to muscles not normally activated by the task being performed. Electromyography may also useful as a guide to botulinum toxin injections. 

X-rays

Radiographs are not useful in the assessment of focal dystonia. Occasionally, in an appropriate setting, magnetic resonance image of the brain can be useful to rule out a cerebrovascular disease. 

Treatment
There is no cure for dystonia at this time, and although treatment of the disorder may be challenging, there are several available options. The different causes of hand dystonia may warrant different treatments. Don't give up--see Leon Fleisher's story.

Oral medications: There are a number of therapeutic agents with clear beneficial effects to writer’s cramp, including anticholinergics, clonazepam and benzodiazepines. High dosage of anticholinergic drugs is firstly recommended for the treatment of dystonia.

• Doses recommended of biperiden are 2 mg per oral two or three times a day and titration to 16 mg a day.
• Diazepam is another choice. However, it is rarely adequate when used as sole agent. Doses are 10mg per oral two or three times a day.
• Clonazepam can be useful for improvement of phasic symptoms in cases with myoclonus and/or tremor. Doses are 0.25 mg per oral twice a day, increasing to 0.125 to 0.25 mg every three days up to a dose of 4 mg/day.

Botulinum toxin injections has been used for the treatment of writer’s cramp with good results. Its application requires careful and precise technique. The selection of the muscle should be based on careful physical examination while the patient writes or plays in order to trigger the dystonic movements. The injection should be carried out under EMG guidance with a hollow recording needle and the botulinum toxin is injected through the same needle. Small volume injections into multiple sites are preferred to a single large injection. Dose per muscle varies from 2.5-25 units. Initially, only few muscles are injected. The dose per muscle and number of muscles injected are optimized (based on response) for subsequent injections. 

Splints

Some patients find that finger-splinting device made individually according to their symptoms help improve their ability to write or to play a musical instrument. Limb immobilization for four weeks and a half is a simple and sometimes effective treatment for this condition. (photo credit) 

"Therapeutic approaches involving the practice of movements are likely to remain unsuccessful unless their design includes a framework that, in principle, aims at interrupting this vicious circle. Indeed, a recently developed behavioural therapy, termed sensory motor retuning, holds great promise (Candia et al., 2002). Musicians with focal hand dystonia performed repetitive movements with fingers of their dystonic hand while one or more fingers except the dystonic ones were immobilized. After therapy, movements of the dystonic fingers were substantially better controlled, with some musicians reaching near-normal performance levels. Along with improvement of motor behaviour, the topography of the somatosensory representation of the fingers became normalized." from Brain article (see references below). 

For an interesting list of people who have struggled with this problem, check here. 

References and Resources

Mark Hallett, MD

NIH clinical study "A Training Protocol for the use of Botulinum Toxin in the Treatment of Neurological Disorders", reference No. 85-N-0195

Focal Dystonia of the Hand by Marcos Sanmartin

Focal hand dystonia – a disorder of neuroplasticity?; Brain, Vol. 126, No. 12, 2571-2572, December 2003; Joseph Classen

Upper Limb Disorders in Musicians by Raoul Tubiana, MD

Tubiana R. Musician’s focal dystonia. Hand Clin 19: 303-308, 2003.

Dystonia Fact Sheet--National Institute of Neurological Disorders and Stroke

Dystonia--pianomap

Focal Dystonia from a Guitarist's Perspective by Jarrod Smerk

A Tale of Two Hands--Charlie Rose talks to pianist Leon Fleisher

Muscians with Dystonia Foundation

What is Plastic Surgery?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

Recently I read an editorial in the Plastic and Reconstructive Surgery (PRS) Journal by Dr. Thomas R Stevenson regarding the question of "What is Plastic Surgery and Who Decides?" It is a very thoughtful article. With his and Lippincott Williams & Wilkins permission, I am re-printing it here. 

"What is Plastic Surgery and Who Decides?"

We are finishing a face lift consultation and my nurse puts away our mirror. Amy, rearranging her hair, asks a familiar question, “Why do they call it plastic surgery?” I fumble through an explanation of Carl von Graefe’s use of “plastic,” meaning “to mold,” and add something about having “nothing to do with a class of chemical compounds, but is a discipline that includes reconstructive and aesthetic surgery.” Amy’s eyes glaze over. Obviously confused but satisfied there is an answer, she walks into my manager’s office for a price quote. I am left with her question and my own interpretation of it. Amy really wants to know, “What is plastic surgery?” The answer depends on whom you ask. 

Quiz a U.S. citizen about our specialty and chances are you’ll receive a response referencing movie stars and breast augmentation. A crude colloquial noun often will substitute for “breast.” You might get a script outline from last week’s plastic surgery reality television show. Press a little further and you may hear a reference to nose jobs and face lifts— occasionally cleft lip repairs or breast reconstructions. If you mention pressure sore closure or limb salvage, digital replantation, or hand surgery, the reply might be, “That’s plastic surgery?” Such is our specialty’s public perception. 

Insurers have a clearer idea of surgery’s scope but limited concerns regarding plastic surgery’s future. Give them an ICD-9 and CPT code, and they will tell you if it is covered and what they will pay. Reimbursement is based on a negotiated fee-for-service scale. A plastic surgeon in private practice can decide if payment is sufficient, accepting only those insurance plans that pay enough and rejecting others. Plastic surgeons in large multispecialty groups or academic practice may not be allowed to turn down patients whose plans reimburse poorly. Thus, most private practitioners are pushed toward performing lucrative cosmetic procedures while other plastic surgeons are threatened with insolvency. Most of us do some cosmetic surgery. That part of our practice requires expertise, involves few emergency calls, and pays the bills. But who among us entered residency simply hoping to be a successful cosmetic surgeon? Unfortunately, if whittled down to a financially viable “chip,” plastic surgery would be one knife stroke away from disappearing. No, third-party payers and financial considerations should not circumscribe our specialty. 

Plastic surgery’s accrediting and credentialing organizations are the Plastic Surgery Residency Review Committee and the American Board of Plastic Surgery. Each group has a slightly different view of what constitutes our specialty. The Plastic Surgery Residency Review Committee precisely delineates the variety and number of procedures each plastic surgery resident must perform in order for his or her program to stay accredited. Provide inadequate case volume and a training program risks loss of accreditation. Through written and oral examination processes, American Board of Plastic Surgery certification is granted only to those candidates who are familiar with a broad range of problems faced by plastic surgeons. The Residency Review Committee and American Board of Plastic Surgery determine what information a plastic surgery residency must impart and what a graduating resident must know to be board certified. These two organizations declare what a plastic surgeon starts out being, not what that surgeon will be doing in a mature practice. 

Plastic surgeons are encouraged by the board to maintain certification. Board certification is time-limited. If a plastic surgeon wishes to maintain certification, that surgeon must regularly assess his or her patient management abilities, identify deficiencies, and objectively demonstrate an effort to improve. However, this Maintenance of Certification process will not force a plastic surgeon to master the same breadth of skills that surgeon possessed when he or she was initially certified. Plastic surgery’s scope cannot be defined by accrediting or certifying bodies.

Plastic surgery training programs develop curricula based on comprehensive didactic and clinical outlines. Program directors are required to educate residents across a wide spectrum. Still, no two programs are identical. Some programs are strong in microsurgery, others in aesthetic procedures. Newly graduated residents are as different as snowflakes. Those differences grow over years of practice. Principles of problem analysis and treatment planning, developed as a resident, should be retained and used to refine patient care techniques. However, specific procedures taught to a resident are supplanted by the discovery of superior ones or are shown to be ineffective, even dangerous. Who among us is still injecting liquid silicone? When a resident finishes training, his or her perspective interprets plastic surgery as that body of knowledge personally amassed to date—but there will be so much more. 

Plastic surgery is defined by public opinion, reimbursement agencies, accreditation and certification bodies, training program curricula, and practice patterns. Is that the entire answer? 

Back to Amy’s question, “What is plastic surgery?” She may never know, but we should. I believe plastic surgery is what plastic surgeons do. It is what we do collectively, and what this aggregate body does is what each of us individually entered plastic surgery to do. Yes, it is constrained by finances, limited by local availability of cases, and confined to its practitioners’ skills and training. Our scope may be narrowed by competing specialties, and certainly our practice will change. Still, we as a group fix clefts, treat pressure sore patients, reconstruct burn victims, repair mangled hands, and care for patients overseas.

As applicants to plastic surgery programs, we were picked because we were capable and promising in our program directors’ eyes. We were young surgeons who looked at things differently. Each of us vowed to be an innovator. We wanted to figure out a new and better way of doing something. Preserving that ideal and providing the chance for enthusiastic, creative young surgeons to flourish is plastic surgery’s essence. Each of us retains a portion of that spirit. Private practitioners, academicians, and researchers in plastic surgery must continue their commitment to variety and innovation. We must encourage the American Board of Plastic Surgery and Plastic Surgery Residency Review Committee to maintain breadth in plastic surgery training. Our membership organizations must be stimulated to provide varied educational offerings. We are obligated to ensure that those opportunities we enjoyed persist and are passed on to the next generation of plastic surgeons.

Thomas R. Stevenson, M.D.
Division of Plastic Surgery
University of California, Davis
Sacramento, Calif. 95817
What Is Plastic Surgery and Who Decides?; Plastic & Reconstr Surgery, 120(4):1079-1080, September 15, 2007; Stevenson, Thomas R. M.D.

Revisit of Community Acquired MRSA--Prevention Tips

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

With the recent death of the Bedford County, Virginia student and today's closing of the schools there for cleaning, I thought it would be prudent to revisit MRSA.  This was first posted on July 30, 2007.

Staphylococcus aureus, or “staph” as it is sometimes called, is a common bacterium found on the skin or in the nose of ~25-30% of humans. Staph aureus is usually harmless, but in certain instances it may cause moderate to severe skin infections. Less commonly, it causes more serious systemic infections: bloodstream, surgical wound and pneumonia requiring hospitalization. One group of staph known as MRSA (methicillin-resistant Staphylococcus aureus) was first identified in the 1960’s. It is now prevalent in most hospitals. The organisms are resistant to multiple antibiotics (specifically, all antibiotics known as beta lactams, as well as other antibiotic families), and are therefore cause for considerable concern. Photo credit

A newer form of staph infection, known as CA-MRSA (for community-acquired, or community-associated Staphylococcus aureus) has appeared with increasing frequency and is now epidemic within certain community populations. Whereas hospital MRSA is almost always found in persons with established risk factors associated with prior medical treatment, these are not present in CA-MRSA. Today, in the U.S. a little more than 10% of all MRSA infections are CA-MRSA. This form causes serious skin and soft tissue infections in otherwise healthy persons who have not been recently hospitalized or undergone invasive medical procedures. Hospitalization is required in approximately one out of five cases.

CA-MRSA has been identified most frequently among specific populations, including prisoners, athletes, children, men who have sex with men, military recruits, Pacific Islanders, Alaskan Natives and Native Americans.

Rather than getting into treatment, I want to highlight was that can help PREVENT getting or spreading CA-MRSA.

1. Clean your hands frequently with soap and warm water or an alcohol-based hand rub.
2. Keep your linens and clothes clean. Wash sports clothing and washable athletic gear with laundry detergent after each use (not after a week or two of use).
3. Do not share personal care items. At home this includes washcloths, towels, and razors. At the gym or school this includes sports towels, sports equipment (helmets, gym mats), uniforms/clothing. Equipment that can't be washed should be cleaned with an antibacterial solution after each use.
4. Take care of skin cuts or abrasions before they get infected. Wash them with soap and water, then cover with a dry, sterile bandage daily. Promptly throw away the old bandage. Wash your hands before and after changing the bandages.

If you are given antibiotics for an infection, it is important to take ALL of the doses. Don't quit "when you feel better" or the skin "looks better". Finish all the doses. The bacteria that don't get killed by the missed doses can morph into tomorrow's superbugs.

Staph Infections--e-Medicine article by Robert W Tolan Jr, MD

Community-Associated MRSA Information for the Public --Centers for Disease Control

Staphylococcus aureus Section--Minnesota Department of Health

APUA Newsletter on CA-MRSA--2003

Digital Photos of CA-MRSA Infections

Pumpkin Carving--Prevent the Injuries

Updated 3/2017-- photos/video and all links (except to my own posts) removed as many no longer active.

Carved pumpkins can be works of art, but carving one incorrectly can leave you with cut fingers. Minor cuts will often stop bleeding on their own or by applying direct pressure to the wound. Most of these cuts and scraps will be minor and can be treated by washing with soap and water initially. Then keep the wound clean and dry while it heals. However, if the bleeding continues after 15 minutes or if you lose the ability to move the finger properly (very likely a tendon injury), then seek medical attention at a hospital emergency department. (photo credit--Headless Horseman)

Let's prevent the injuries. Here are some tips:

• Carve in a clean, dry, well-lit area.
  If your tools, hands or cutting table are wet, this can cause slippage and lead to injuries.
• Always have adult supervision (without alcohol use)
  Children under age five should never carve. Instead, allow kids to draw a pattern or face on the pumpkin and have an adult carve. Allow the child to be responsible for cleaning out the inside pulp and seeds. They can use their hands or a spoon for this. Children, ages five to ten, can carve but only with adult supervision.
• The right way to cut.
  You should always cut away from yourself in small, controlled strokes. A sharp knife is not necessarily the best tool because it often becomes wedged in the thicker part of the pumpkin, requiring force to remove it. An injury can occur if your hand is placed incorrectly when the knife dislodges from the thicker part or slips.
• Use a pumpkin carving kit.
  Special pumpkin carving kits are available for purchase and include small serrated saws that are less likely to get stuck in the thick pumpkin. If the saw does get stuck and then becomes free, it is not sharp enough to cause a major cut. Fewer injuries occur with use of carving kits. (photo credit)

Here is a link for instructions and patterns for pumpkin carving at Spook Master. And here are just some fun photos I found:

George Bush at Jack of All Blogs

Happy Halloween (Jim Hendricks, bbc.co.uk)
Ping the Pug (photo credit)

Once carved, it is important to remember to KEEP dogs and cats away from Jack o'Lanterns or lighted candles as they could knock them over and start a fire.
Have a safe Halloween season!

Spit for the Cure

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

The local Susan G Komen Race for the Cure is this Saturday in Little Rock, AR. The University of Arkansas Medical Sciences (UAMS) is using the event to collect saliva samples from thousands of women. The samples will be used to used to create a DNA database for future studies related to breast cancer risk and treatment. Participants in "Spit for the Cure" will be asked to answer a short questionaire. All information is to be kept confidential and the samples are to be labeled by number not name. The leading researchers are Susan Kadlubar, PhD, assistant professor of environmental and occupational health in the UAMS College of Public Health, V. Suzanne Klimberg, M.D., director of the breast cancer program at the UAMS Winthrop P. Rockefeller Cancer Institute (formerly the Arkansas Cancer Research Center), and Kristy Bondurant, Ph.D., postdoctoral fellow. (photo credit)

“It has become clear that an individual’s inherited profile and environmental exposures will decide, to a large degree, that individual’s risk of developing breast cancer. We are working to obtain DNA samples from a representative group of Arkansas women that will be used to advance breast cancer research in a variety of areas.” Suzanne Klimberg, MD

A rare chance to spit in public and it be sociable acceptable.
Trail Manners by Wendy Bumgardner
Manners and Etiquette in the Antebellum South

SurgExperiences 106

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

SurgeXperience 106 is up over at IntraopOrate. Though she bemoans "Due to time constraints (and perhaps a lack of imagination!) the format of this edition is more practical than clever." I think she did a wonderful job! Check it out. I think you'll find many posts that you enjoy reading.

The Great Arkansas Quilt Show II

Last night was the awards presentation for the Great Arkansas Quilt Show II hosted by the Historic Arkansas Museum. I had entered two quilts, Flowers in a Vase (seen in the upper left corner of the blog page) and Will the Circle Be Unbroken (below, center quilt of the first photo). I did not expect to win any awards, but did. Will the Circle won "Best Hand Quilting".

Will the Circle Be Unbroken (center)
center of Flowers for Mattie by Irma Gail Hatcher

Peach Sherbert, an absolutely beautiful quilt

I need to get better at taking notes for my pictures.

This one has 50 different blocks, all in red and white. Very lovely.

A lovely quilt using the lone star pattern.

An applique of nursey rhymes

Flowers and Cats

I really like this one. It feels like Christmas.

A stunning appliqued quilt!

Another pretty red and green pieced quilt.

I wish you could see this in person. My photo does not do it justice!

Another lovely applique of flowers much prettier than my photo shows.

Beautiful blue and white pieced quilt!

Flying Birds

Generic Drugs

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

I was on my way to the office this morning when I heard this NPR story "Study: Generic Anti-Depressant Ineffective by Joanne Silberner." It is extremely rare that I don't mark the box --allow generic substitute -- on the prescriptions I write. When I am the patient, I ask for generics. So this news report gave me pause. According to the FDA, the definition of a generic drug is:

"A generic drug is identical, or bioequivalent to a brand name drug in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. Although generic drugs are chemically identical to their branded counterparts, they are typically sold at substantial discounts from the branded price."

The same FDA page goes on to reassure:

"Health professionals and consumers can be assured that FDA approved generic drugs have met the same rigid standards as the innovator drug. To gain FDA approval, a generic drug must:

• contain the same active ingredients as the innovator drug(inactive ingredients may vary)
• be identical in strength, dosage form, and route of administration
• have the same use indications
• be bioequivalent
• meet the same batch requirements for identity, strength, purity, and quality
• be manufactured under the same strict standards of FDA's good manufacturing practice regulations required for innovator products"

I am like "Cheryl" in the NPR story, I am a fan of generics. Still if you (and your doctor) do not feel that you are getting the benefits expected from your prescription, you may want to try the "name" brand.

Toradol

Updated 3/2017-- photo (except for my own) and all links (except to my own posts) removed as many no longer active.

Okay, so here's the deal. Ten years or so ago, I used toradol in most patients. That included breast implant patients. It really cut down on how much postoperative analgesic use. Then one of the older plastic surgeons in town mentioned that if I had a postoperative hematoma in one of my breast augmentation patients that I would have a difficult time defending myself in a law suit. I quit using toradol in all implant patients, but still used it in reduction patients, etc. Recently, I have had repeated discussions with a CRNA regarding the use of toradol in breast augmentation patients. I don't like my reason for not using it in these patients. So I went back to the literature to either remove my reason or bolster it. The literature was not much help. There doesn't seem to be any really great studies out there for either side. Here is what I found. Anyone have any other information to help me out? (photo credit)

Toradol (ketorolac tromethamine) causes significant inhibition of platelet aggregation by inhibiting cyclo-oxygenase and decreasing thromboxane A1 production. Ketorolac also inhibits platelet aggregation in response to collagen and arachidonic acid. Platelet aggregation is decreased by 25% three hours after a dose of ketorolac. Unlike the prolonged effects from aspirin, the inhibition of platelet function by ketorolac disappears within 24 to 48 hours after the drug is discontinued. This inhibition of platelet aggregation results in a significant prolongation of bleeding time. Healthy volunteers demonstrated prolonged bleeding times (from 4.9 to 7.8 minutes) after five days of parenteral ketorolac. Ketorolac significantly prolonged skin bleeding time from a baseline of 222 to 299 seconds one hour after an intramuscular dose in 50 surgical patients. Ketorolac does not affect platelet count, prothrombin time (PT) or partial thromboplastin time (PTT). Postoperative hematomas, operative site bleeding and other signs of would bleeding have occurred rarely with perioperative use of ketorolac. In controlled clinical studies, the incidence of clinically significant post-operative bleeding was 5/1170 (0.4%) compared to 1/570 (0.2%) in the control groups receiving opiates. Therefore, caution should be exercised where strict hemostasis is critical.

Dosage and Administration

Ketorolac tromethamine must not be used in children under 16 years of age. In adults, the loading dose is 30 to 60 mg IM/IV followed by a maintenance Dose --15 to 30 mg IM/IV every 6 hours or 10 mg po every 8-12 hours. Maximum Dose --150 mg on first day, then 120 mg per day, not to exceed 5 days.

Dosing Adjustments --A 30 mg loading dose and maintenance dose of 15 mg IM/IV q6h should be used for patients weighing 50 kg (110 lbs), patients over 65 years of age, or patients with decreased renal function (CrCl between 30 to 50 ml/min), and use should be discouraged in patients with CrCl less than 30 ml/min.

Ketorolac injection is indicated for the short-term management of pain, up to 5 days only. It is recommended to convert to oral NSAID therapy when the patient can tolerate oral medications. Concomitant use of anticoagulants (e.g., heparin, enoxaparin, warfarin) increases the risk of bleeding complications. Concomitant use of other NSAID therapy, including aspirin, may produce additive adverse effects.

The lowest effective dose should be given. A total daily dose of 90 mg for the non-elderly and 60 mg for the elderly should not be exceeded. (inserted article from the 5th reference below)

References

• The Rational Use of Parenteral Ketorolac; Nancy E. Sloan, Pharm.D.; P&T News: May 1994, Vol. 14, No. 11
• Incidence of hematoma associated with ketorolac after TRAM flap breast reconstruction; SHARMA Sanjay, CHANG David W., KOUTZ Cindy, EVANS Gregory R. D., ROBB Geoffrey L., LANGSTEIN Howard N., KROLL Stephen S.; Plastic and Reconstructive Surgery Journal, Vol 107, No 2, pp 352-355, 2001 (abstract here)
• Facial plastic meeting yields surgical pearls; Source: Dermatology Times, Originally published: June 1, 2002
• POSTOPERATIVE HEMATOMAS ASSOCIATED WITH TORADOL; Plastic & Reconstructive Surgery. 88(5):919, November 1991; Garcha, Iqbal S.; Bostwick, John M.D.
• PERSONAL EXPERIENCES WITH TORADOL; Plastic & Reconstructive Surgery. 89(6):1183, June 1992; Dowbak, Gregory M.D.
• The Effect of Ketorolac on Microvascular Thrombosis in an Experimental Rabbit Model; Plastic & Reconstructive Surgery. 98(1):140-145, July 1996.; Shufflebarger, John V. M.D.; Doyle, James Ph.D.; Roth, Tim M.S.; Maguire, Kevin M.D.; Rothkopf, Douglas M. M.D.