Pedometers and Physical Activity

I use a pedometer as a reality check. I often go home tired after a day in surgery or in the office. I'm tired so I must have expended a lot of energy and therefore used a lot of calories/done a lot of moving right? Wrong! In the course of a "normal" day most adults take anywhere from 900 to 3000 steps in a day and not much more. That means to truly get "enough" physical activity in daily, I (and you) need to go for that daily walk. Fortunately, I enjoy walking. Most days (barring horrible weather) I enjoy my walks with my dog. Other days--I just do it--rain or cold or heat. This is a picture of my pedometer with my step count on a surgery day. It includes the time from getting dressed to just finishing in the operating room. Notice how few steps have been taken.

JAMA recently had an article (referenced below) that showed "The results suggest that the use of a pedometer is associated with significant increases in physical activity and significant decreases in body mass index and blood pressure." Overall, the pedometer users increased their physical activity by 26.9% over baseline. The person who gets the most out of the use of a pedometer is the who has a step goal (ie 10,000 steps per day).

The JAMA article also found "Pedometer users also significantly decreased their systolic blood pressure by almost 4 mm Hg from baseline. Reducing systolic blood pressure by 2mmHg is associated with a 10% reduction in stroke mortality and a 7% reduction in mortality from vascular causes in middle-aged populations; thus, it is critical that the effects of pedometer use on blood pressure be examined closely in future studies."

Perhaps you might think about getting a pedometer for someone for Christmas or even one for yourself. It does not need to be an expensive one. I use the Sportline 340 (having lost a few, they cost less to replace). I never bothered to program in my step length. I simply use it to count the steps and aim for that 10,000 mark. Most days I go past it, but there are days I have to "work" at it. Simple adjustments will add up--park the car farther away from the store, take the stairs down two flights or up one rather than using the elevator, walk one extra block, etc.

Some suggestions on getting started with your new pedometer...

• Start out by wearing the pedometer each day for two weeks and don't do anything to change your normal routine. Keep an exercise log of the daily step count. At the end of the second week, take a look at how many steps you are taking each day in the course of living your life.
• If you feel comfortable doing so, take the highest number of steps you have walked on any given day during that 2 week period. Use that number of steps (ie 2500 steps) as your first daily step goal. To avoid injury, do not select a higher number. Continue to keep your step log.
• At the end of that two week period, review all the steps you took each day. If you are ready, add another 500 steps to your daily goal. Your new step goal is now 3000 steps a day for the next two week period.
• Continue in that manner, working up until you finally reach the goal of 10,000 steps a day.
• The goal is to keep you active for the rest of your life. So don't go overboard and injury yourself. Take it slow. Take it easy.
• It takes about six months to "lock in" a new behavior. Aim to do what is necessary to change your exercise behavior permanently. Be prepared to dedicate yourself to your daily goal each day for a minimum of six months. If you do that, you are much more likely to maintain this goal permanently.
• If you skip a few days due to illness, work or other obligations, the sooner you get back into the exercise groove, the more likely you will be able to get back into your routine.
• Reaching that walking activity goal of 10,000 steps does not mean that you can increase your food intake. Continue to try to eat a healthy and reasonable portion diet.
• So the weather's yucky, walk laps at the mall, go to a museum, or walk laps inside your home. Get up and move!

Here's my total at the end of the day.

References

Using Pedometers to Increase Physical Activity and Improve Health: A Systematic Review; Dena M Bravata, MD and others; JAMA, Nov 21, 2007, Vol 298, No 19, pp2296-2304

Shape Up America! 10,000 Step Program

Suture Self

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

Shortly after I began my blog, I got a message through mybloglog from Dr. Judy Paley (Denver Doc Online), "I thought of the greatest name for your blog: Suture Self."

I answered her back something like "I kind of like the play on words I had--similar to working for a living." I still like the name of my blog.

However, the other day in Barnes and Noble while perusing books this book caught my eye. The title, Suture Self, reminded me of FemaleDoc's comment back in June. So I had to buy the book and am reading it now. It's not heavy reading, but is entertaining.

The synopsis: A bum hip has bed-and-breakfast hostess Judith McMonigle Flynn limping off to Good Cheer Hospital -- a questionable "haven of healing" where two recent patients didn't make the cut after routine surgery. Judith's trepidation at undergoing the knife is eased only by sharing a room with cousin Renie, who's in for rotator cuff repair. Though the cousins survive their surgeries, the ex-pro quarterback next door is permanently sacked after minor knee surgery. With the scoreboard showing Grim Reaper 3, post-op patients 0, Judith decides that she and Renie are obliged to get to the bottom of Good Cheer's carnage. But in order to sew up the case, Judith and Renie must probe into the suspects' psyches. And suddenly it looks as if the cousins' own prognoses could take them out of the game...for good.

I wonder if I had changed my blog name to "Suture Self" if I would have been in violation of copyright.

Wrong Side Surgery

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

There is another incident of wrong side surgery in the news. I find it as difficult to fathom as I do leaving a baby in a hot car, but we know that happens to0 often (once is too often for either).

"The Rhode Island Department of Health reprimanded Rhode Island Hospital today, and fined it $50,000, for its third wrong-site surgery this year, the most recent involving an 82-year-old patient in the neurosurgical intensive care unit.

The incident at the Providence hospital occurred Friday, when a resident, a doctor in training, began drilling into the right side of the patient's head during a bedside procedure. A CT scan had shown bleeding on the left side of the patient's brain. The resident realized the mistake, stitched closed the initial incision and performed the procedure on the left side." --White Coat Notes

Wrong-site surgery is a medical error that should never happen. It is not a medical risk that the patient must accept. Legally, it qualifies under the principle of res ipsa loquitur. The National Quality Forum (NQF) includes wrong-site surgery events on its list of Serious Reportable Events (commonly referred to as never events).

Wrong-site surgery is surgery that is:

• done on the wrong patient--8%
• the wrong procedure--9%
• the wrong side of the body (ie, as above, or left knee rather than right knee)--70%
• or the wrong part of an anatomic structure (ie wrong spinal level in back surgery, wrong finger in the correct hand) --14%

Above percentages taken from the MedScape article listed below.

Wrong-site surgery is a core patient safety problem. It is the responsibility of everyone who is part of the patient's care. "The actions of surgeons in verifying the reconciliation process in the preoperative area were found to have the greatest net positive contribution (+42), followed by the patient or family (+38) and then verification against the surgeon's office records (+29). Nurses in the preoperative area and those circulating in the operating room were equally effective at identifying errors (+17)." Suggestions for preventing the occurrence of wrong-site surgery:

• The surgeon should be fully engaged in the formal time-out. He/she should consider a full preoperative briefing.
• The surgeon should be explicit about the procedure and its indication(s), including the side or site as appropriate. This should be included in the patient's records (ie H&P).
• The consent should be obtained from the patient by the surgeon, explicitly stating the procedure including the side or site as appropriate.
• There should be a reliable system for accurately transmitting information from the surgeon's office to the OR nurse.
• Have an initial-time out in the OR before caring for a patient undergoing elective surgery.
• The marking of the operative site should be reconciled by the surgeon and patient together.
• The surgeon should discuss new findings and changes in plans with other members of the operating team.
• Labeling the specimen--reconciliation should include the surgeon, the operating technician, and the circulating nurse. There should be a chain of custody for irreplaceable specimens.
• Multiple and ancillary procedures should be included in the formal timeout.
• Repeat formal time-out processes for independent procedures.

Most important is for everyone involved to be engaged in the process. Remember why we are in the operating room. It is to take care of the patient--someone's mother or father or brother or sister or daughter or son. Tomorrow it may be one of us. Take care.

Reference
Getting Surgery Right, Preventing Wrong-site Site Surgery--MedScape Article
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery ™ -- the Joint Commission
Wrong-site Surgery-- Agency for Healthcare Research and Quality

DeBakey and Cooley

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

There is a very nice article in the New York Times today (thanks to Dr Anonymous for the tip) on the forty plus year feud between Dr. Michael A. DeBakey (now 99 yr) and Dr. Denton A. Cooley(now 87 yr). It highlights some important medical/surgical history.

"The breach began in 1960, when Dr. Cooley left Dr. DeBakey’s practice at Methodist and moved the few hundred yards to St. Luke’s Hospital, where he later established the Texas Heart Institute. But it was an incident in 1969 that turned the rift into a full-blown feud.
It happened when Dr. Cooley, without approval from Dr. DeBakey or Baylor, commandeered an artificial heart from his former partner’s lab and implanted it in a patient at St. Luke’s.
Over the years, Dr. DeBakey has called that first-ever use of a total artificial heart a theft, a betrayal, unethical and “a childish act” to claim a medical first. Dr. Cooley defended the implant as a desperate, if ultimately unsuccessful, act to save a life."

Extravasation Injuries from Chemotherapy

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

Recently Buckeye Surgeon wrote about a complication of chemotherapy (severe neutropenic enterocolitis) that necessitated removal of some dead bowel. It recalled for me the skin injuries I have been called to see over the years. Fortunately, I haven't seen any in several years. Still, I thought I would review the injuries and share them with you.

Extravasation injury is a well-known adverse event associated with intravenous chemotherapy administration and occurs when drugs escape from the veins or intravenous catheters into subcutaneous tissues. Accidental extravasation occurs in approximately 0.1 to 6% of patients receiving intravenous chemotherapy. Cancer patients are inherently at high risk of extravasation for several reasons. These patients often require multiple venipuncture sites and have thin and fragile veins, concomitant peripheral vascular disease, and malnutrition. In addition, the number of optimal intravenous sites may be reduced due to previous chemotherapy, cutaneous radiation therapy changes, and lymphedema secondary to surgery.

The cutaneous manifestations of extravasation may range from discomfort and mild erythema to severely painful skin necrosis, ulcerations, and invasion and damage of deep tissue structures. The extent of tissue damage in extravasation largely depends on the concentration, volume, and vesicant nature of the extravasated agent.

Extravasated cytotoxic agents generally cause two types of local cutaneous reactions:
Irritant Reaction

• Irritants cause a short-lived and self-limited phlebitis and tender, warm, erythematous reaction along the vein or at the site of intravenous administration.
• A variant of this local irritation is an erythematous and urticarial hypersensitivity “flare reaction” that has been associated with the anthracyclines (Daunorubicin, doxorubicin, and epirubicin).

While almost all vesicants exhibit some degree of irritation on a spectrum of injury, carboplatin, cyclophosphamide, docetaxel, ifosfamide, menogaril, and thiotepa are known to produce irritation, but have not been reported to cause chemical cellulitis. If these agents do have vesicant activity, it is likely to be very minimal and rare.

Vesicant Reaction

• Chemical cellulitis which initially presents in a similar way to irritation but may worsen, depending on the amount of drug that has extravasated. The erythema associated with small-volume extravastions will usually resolve over a few weeks. Chemical cellulitis is rare with fluorouracil and less severe with vinblastine and vincristine.
• Necrosis--Large-volume extravasations may induce necrosis within a matter of days. Eschars generally follow with subsequent development of painful ulcerations with red, raised edges. It has been estimated that about one-third of all vesicant extravasations will develop into ulcerations. (photo credit)
• Extravasation recall reaction--This is a reaction at a previous extravasation site that happens when there is an extravasation at a new site. This reaction can range from erythema to ulcerations. It has been seen with Paclitaxel.

Chemical cellulitis displays poor healing activity and often continues to worsen and progress, necessitating surgical intervention. Rudolph and Larson have reported that vesicant-induced damage to the skin delays fibroblastic wound contraction. The ability of these vesicants to bind to DNA may allow them to be recycled and retained in the tissue, thereby inducing damage for a longer duration.

Management
Vigilance in the proper and timely recognition and management of extravasation plays a major role in limiting tissue injury. When extravasation is suspected:

• Prompt discontinuation of the infusion is recommended
• Aspirate any residual drug and removal of the catheter.
• Apply local cold application--Intermittent local cooling (for 20 minutes QID x 3 days) alone has an 89.1% success rate in preventing ulceration. For the vinca alkaloids, heat application (apply heat packs for 20 minutes QID x 3 days) is recommended instead, as cold application may actually induce ulceration.
• Elevate the affected extremity

The use of antidotes is controversial. Some antidotes such as sodium bicarbonate may be harmful or ulcerative.

• On September 6, 2007, the U.S. Food and Drug Administration approved dexrazoxane hydrochloride for injection (Totect™ made by TopoTarget USA, Inc.), equivalent to 500 mg dexrazoxane, for the treatment of extravasation resulting from IV anthracycline chemotherapy. The first dexrazoxane hydrochloride dose should be given as soon as possible and within six hours following extravasation. After the first dose, treatment is repeated 24 and 48 hours later for a total of three doses. Dexrazoxane hydrochloride is administered as a 1-2 hour IV infusion through a different venous access location.
• Sodium thiosulfate has been recommended for mechlorethamine. Use 4ml 10% sodium thiosulfate + 6ml water and instill via multiple injections in and around the area of extravasation (ie. SQ/ID) using a small gauge needle (eg. 25g).
• Hyaluronidase had been recommended for vinca alkaloids (Vincristine, Vinblastine, and Vinorelbine). Use 150U (1ml) and instill via multiple injections in and around the area of extravasation (ie. SQ/ID) using a small gauge needle (eg. 25g).
• Locally injected corticosteroids --the results have been variable. As few inflammatory cells are involved in extravasation reactions, these reactions may not be inflammatory and would not, hypothetically, benefit from locally injected corticosteroids.
• Locally injected granulocyte macrophage colony-stimulating factor (GM-CSF) has been used to promote healing of doxorubicin ulcerations. It needs more study.
• Pyridoxine has been used to treat mitomycin extravasation, This also needs further study.
• Locally injected saline alone has proven successful in resolving extravasation reactions and preventing ulceration.

While conservative treatment is preferable for most vesicant extravasations, early excision is sometimes favored, especially when the most potent vesicants are involved. Surgical consultation for wide local excision and flap reconstruction is invariably necessary when ulcerations become evident, or if extravasation lesions prove unresponsive to therapy.

For topical therapy, the free-radical scavenger (DMSO) has shown consistent therapeutic success. Use 50-70% solution (1.5ml) and apply topically (ie. "paint" on the skin) QID x 14 days. Leave uncovered. DMSO has been recommended as an antidote for extravasation of Doxorubicin and Daunorubicin as well as Mitomycin. In 1995, an analysis of 96 cumulative patients from multiple studies showed that DMSO protected 98.3% of extravasation cases from ulceration.

Prevention is always the most effective measure in managing extravasation and includes use of a central line or a carefully chosen site of administration.

• The use of a central venous catheter (CVC) or port is recommended for continuous infusion therapies. However, the use of CVC administration does not prevent extravasation injury, since devices may be dislodged, or venous vessels may be perforated with potentially disastrous consequences, including mediastinitis. Thus, central extravasation should be considered in the differential in the presentation of fever, severe pleuritic pain, upper extremity and neck swelling, and a widened mediastinum.
• In the case of peripheral intravenous administration, the selection of sites should be in the order of forearm, dorsal hand, wrist, and antecubital fossae (inner elbow), on the basis of the presence of vital underlying structures. Optimally, vesicants should not be given in areas of recent administration, irradiation, or lymphedema. It is also wise to avoid sites, which are distal to a recent site of venipuncture, as leakage could occur at these sites.

References
Cancer Medicine e.5; by BC Decker Inc. First published 1981. Fifth Edition 2000
Preventing and Managing Peripheral Extravasation; Nursing, May 2004 by Hadaway, Lynn C
What is the appropriate management of tissue extravasation of antitumor agents?; Plastic and Reconstr Surg 75:397-402, 1985 ; Larson DL
Discussion - What is the appropriate management of tissue extravasation of antitumor agents?; Plastic and Reconstr Surg 75:403-405, 1985: Dorr RT

SurgeXperiences 109 is Up!

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

SurgeXperiences 109: The Weird Ones and Others is up over at Monash Med Student. I hope you will go over and check it out. Though the theme is not strickly stuck to, Jeffrey did a nice job presenting you with some good reads. So grab a good cup of coffee (or whatever) and settle in. (photo credit)

The next edition of SurgeXperiences will be its 10th. It will be hosted 2 weeks from now at by Dr Alice at Cut on the dotted line on 9 December. Further details can be found there.

Diabetic Mastopathy

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

"Diabetic mastopathy, also known as sclerosing lymphocytic lobulitis, is characterized by benign, firm, painless, mobile, irregular masses most often found in both breasts of patients with a long history of Type I diabetes. Diabetic mastopathy rarely occurs in Type II diabetics. Patients with diabetic mastopathy often have a history of poor glucose control with related complications such as retinopathy, neuropathy, and nephropathy. Rarely, patients with other endocrine diseases will present with diabetic mastopathy.

The incidence of diabetic mastopathy varies widely: from 1 in 1,700 women screened in a breast clinic to 13% of Type I diabetic women ages 20 to 40 in a diabetic clinic."

(A) keloidal-like stromal fibrosis (20x magnification, H&E stain) and (B) mild lymphocytic lobulitis and surrounding fibrosis (10x magnification, H&E stain) complete the classic pathologic description of diabetic mastopathy.

The above text and photos are from a nice article in the current (November 2007) issue of Contemporary Surgery Journal by Matthew Borgo, BA, Shaheen Zakaria, MD, and David Farley, MD. It can be accessed online (with free registration) here. It is worth reading.

You will also find a nice video library of surgical techniques at the Contemporary Surgery website. Check it out.

Post-Thanksgiving Activities

It's the day after Thanksgiving. I am using up left-oversdoing a "Sunshine and Shadows" pattern,

and taking it easy.
Later we'll go for a walk.
Hope you are having a great day!

Thankful

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

Ask my husband--sometimes I grumble and complain. Often more than I should. Often about petty stuff. But not today. Today I want to give thanks. I want to tell you that I enjoy washing dishes. I don't enjoy drying them. It goes back to my childhood when my sisters and I had to do the dishes. One would clean off the table, one would wash, and one would dry. The one who dried also had to put the dishes away. I liked washing the dishes. It was nice to look out the window and see the cows, the apple trees, Mom's flowers, etc. It was nice to be in the "middle" of things. It was nice to "chatter" with my sisters as we did those dishes. Even now, so many years later, I don't mind washing dishes. I rarely use our dishwasher. I usually leave the dishes to dry on their own, and put them away later. My mother always insisted that we offer to help wash the dishes after eating a meal at someone's home. It stuck. I still offer. I always mean it. So when I saw this poem over at Nurse Ratched's I just thought I would second her thoughts. Thank God for dirty dishes. (photo credit)

Happy Thanksgiving! Wishing you many dirty dishes.

"Thank God For Dirty Dishes"

Thank God for dirty dishes,

they have a tale to tell,

While others are going hungry,

we’re eating very well.

Home, health, and happiness,

we shouldn't want to fuss,

With the stack of evidence,

God is good to us.

(author unknown)

Another Tactile QOV Quilt

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

Back in June I wrote about the need for tactile quilts for blind or sight-impaired soldiers. The tactile sense training seems to help them train the brain to "see" in other ways. The reason is not fully understood, but is known as sensory substitution. This refers to the capacity of the brain to replace the functions of a lost sense by another sensory modality. The most commonly used form of sensory substitution is Braille reading which allows the blind to read by touch (somatosensory system).

For the one I am working on now, I used cottons, washable fake fur (polyester zebra print), and old denim. There are four working pockets from the black denim jeans (trouser style). One pocket even has the button-flap. I hadn't intended for it to look "Christmasy" but it does. It is black and white, red, and green in color. The backing fabric is a flannel of the same colors. I am doing a simple "out-line" quilting stitch on my sewing machine. No hand quilting for these thick fabrics (the denim and fake fur). It does have a "nice touch". I hope to finish it over this weekend between family events.

I don't have a name for this pattern. I found this "picture puzzle" in the paper and adapted it.

Here is the flap pocket.
The finished quilt size is 52" X 62".

Grand Rounds 4:09

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

I don't have any posts highlighted in Grand Rounds, but I would like to send you over there. Enrico (Mexico Medical Student) has done a wonderful job. The music he highlights is enough to send you there. The posts he links are just extra.

"In the Thanksgiving spirit, all of today’s selections will highlight American composers. Since all links here are set to open in new windows (or tabs), you can read articles while leaving this window playing in the background. In all but one shorter case, the selections are about 8 minutes each; I hope you indulge my desire to share. Enjoy!"

YouTube - Andra Voldins and Mark O'Connor Appalachia Waltz

NanoScience and Medicine

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

I am on the Industrial Advisory Committee of the University of Arkansas' microEP Graduate Program. At my first meeting this past spring, I found myself feeling out of place as each person introduced themselves and their credentials. The other members come from companies such as Power Technology Inc, Air Force Research Lab, ITT Industries Space Systems Division, Texas A&M, Genesis Technology, Space Photonics, Lockheed Martin Coherent Technologies, Texas Instruments, and Bell Labs. I truly felt as if I might not have anything to contribute. I had been asked to serve on the committee because I was a graduate of the Physics Department (1978), was in health care, and was willing.

The program is an "interdisciplinary graduate program designed to expand a student's knowledge beyond the boundaries of traditional departmental based graduate programs. Students in the Microelectronics-Photonics program will participate in cross-departmental research, will take applications-intensive classes from multiple engineering and science departments, and will develop workplace productivity skills in a simulated industrial environment.
The outcome of their graduate education in this interdisciplinary environment will be a better understanding of microelectronic-photonic materials; the creation of high-performance, miniaturized devices and systems made from these materials; and an understanding of the economics that affect successful introduction of these devices and systems into industry and the community."

I feel as if I may get more out of this association than they do. I will get to learn more about these nano-particles which are amazing. I recently meet a science writer, Lakshmi Gopal, through on-line friends. She sent me this article on Nanotubes in Biomed Applications. It highlights the wonderful possibilities of this technology in medicine. Check out the article, it is a very good read. (photo credit)

SurgeXperiences 109--Call for submissions

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

Haree Haree!

SurgeXperiences 109 (the only surgery blog carnival) is coming to Monash Medical Student next Sunday, November 25. He is accepting all posts related to surgery and your experiences from surgeons, attendings, residents, anesthesiologists, nurses, students, patients, etc.

You can submit your articles to Jeffery via this form. If that fails for some reason or another, there is always his e-mail.

photo credit

The Gift of Life

I try to give blood a few times a year. I have no luck getting my husband to give. I hope I can convince a few of you to give. As we approach this Thanksgiving and Christmas season, there is a gift you can give that will not cost you any money--just a little time and yes a needle stick. But compared to the good it will do for someone like Dr. Smak's son Henry, what's a little needle stick.

And since most of us aren't close enough to Dr. Smak or her family to give then a physical hug or take them a casserole dish or do a load of laundry for them, this is a way that those of us who have befriended her in this cyber-world can do something for them (or another family like theirs). So please give blood this "giving season". As the t-shirt says, you'll be giving someone another birthday, another anniversary, another chance.

Mastopexy

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

Mastopexy, or breast lift, is a procedure designed to improve the appearance of sagging or ptotic breasts (pick them back up). The goal of surgery is to improve the shape of the breast while minimizing visible scars. Many procedures and many modifications of the mastopexy have been suggested to try to achieve this end result.

The classification system (suggested by Regnault and modified by numerous authors) is as follows:
Grade 1: Mild ptosis -

• Nipple just below inframammary fold but still above lower pole of breast

Grade 2: Moderate ptosis -

• Nipple further below inframammary fold but still with some lower pole tissue below nipple

Grade 3: Severe ptosis -

• Nipple well below inframammary fold and no lower pole tissue below nipple; "Snoopy nose" appearance

Pseudoptosis -

• Inferior pole ptosis with nipple at or above inframammary fold; usually observed in postpartum breast atrophy

There are no medical treatments of breast ptosis. It takes surgical removal of skin and/or adding an implant to fill up the excess skin envelope. There are no absolute contraindications for breast lift surgery. However, if you plan future pregnancies, because lactation and subsequent involution will further change the shape of the breast, it is best to delay the mastopexy surgery until after those future pregnancies. In patients who are at high risk of primary or recurrent breast cancer, consideration of whether a mastopexy will alter the breast architecture and add scar tissue within the breast tissue needs to be considered, as this may make detection or treatment of cancer more difficult. It is best to be a non-smoker.

Some guidelines for surgical correction:
Minimal or minor breast ptosis

• can be corrected with breast implant augmentation.
• can be corrected with periareolar skin resection (around the nipple complexwith or without augmentation. (photo credit)

Grade 2 ptosis

• Minor grade 2 can be corrected using a circumareolar donut mastopexy including the cerclage techniques as described by Benelli.
• Moderate grade 2 ptosis can be addressed using the vertical scar mastopexy procedures, including the Regnault B technique and Lejour/Lassus techniques. (photo credit)

Severe grade 2 ptosis and grade 3 ptosis

• This degree of ptosis usually requires inverted T incisions regardless of the pedicle used. (photo credit)

Pseudoptosis

• can be addressed with augmentation and/or skin excision without nipple transposition (excision of lower pole skin) or with the circumareolar cerclage technique.

Complications:
General complications can include bleeding, infection, and problems secondary to anesthesia.

Specific complications include skin necrosis, sensation changes, and asymmetry. Seromas and hematomas, although relatively uncommon, can pose significant problems when they occur. Nipple necrosis can occur due to tension, torsion, or pedicle compression. Overaggressive undermining can lead to necrosis of the skin flaps or NAC. Neither necrosis of the nipple nor skin flap loss occurs frequently. The inverted T incision increases wound breakdown at the junction of the 3 limbs. Scars usually heal without hypertrophy problems.

Asymmetry is almost always present preoperatively, and it is unlikely to be eliminated completely regardless of the technique employed or the experience of the surgeon. Augmentation performed in conjunction with mastopexy can make correction of asymmetry even more difficult.

The periareolar approach can result in under projection of the central portion of the breast, in addition to stretching of the areola. When augmentation is performed with mastopexy, risk of postoperative asymmetry is increased. Augmentation brings its own complication/risk list (capsule formation, deflation, etc).

Something to think about:

The lift done alone does not tend to change your breast size (volume). An exception to this is extreme Grade 3 ptosis where the amount of skin removed may be large enough to make a perceptible change in volume.

So when thinking about having a breast lift with or without an augmentation, give some thought to whether you want breasts the same size or larger when healed. If you want to be the same size, only "picked up" then the scars needed will be worth it. If you want to be larger, then you will have to be willing to have breast implants added into the picture. Go into this informed and don't let your surgeon tell you that you need an implant if you don't want to be larger breasted. I say this because I have removed implants for a couple of women this year who only wanted to be lifted (and are okay with their scars) and did not want to be larger in the first place. Their first surgeon "talked" them into the implants (smaller scars) which they then had removed--both within less than two years after the first procedure (augmentation procedure).

References
Breast Mastopexy by Jorge I de la Torre, MD--eMedicine Article
Breast Lift Mastopexy Videos and Movies Before and After Surgery Gallery--Michael Bermant, MD
Breast Lift (Mastopexy)--American Society of Plastic Surgeons
Photo of Grade 3 Ptosis, before and after correction, no implant--Dr R. V. Dowden
Surgery of the Breast: Principles and Art By Scott L. Spear--Google eBook (or purchase through Amazon.com)

They didn't fall.

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

She'd just had a mastopexy the week before and was in for her first postop visit. Before I had a chance to ask how she was, she said to me, "When I went in the bathroom to shower for the first time and took the bra off, you know what struck me?"

I said what I thought she would say because it's what most patients focus on early postop, "The incisions, the new cuts." I was ready to give her a pep talk.
Her reply, "No. They didn't fall. They stayed up! I love them."

She was truly thrilled. I was thrilled. She'd given me a new perspective to give to future patients. Instead of just telling them to remember that the fresh incisions will heal and the scars will fade, I can remind them to "notice that they didn't just fall when you took your bra off".

(photo credit)

Emergiblog News

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

Change of Shift is up over at Emergiblog. Kim states that it is the best of the nursing blogosphere! And I, for one, listen to good nurses. So head over and check it out.
Then tonight Dr. Anonymous will be interviewing Kim on BlogTalkRadio so if you can tune in.

SurgeXperiences 108

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

I am so happy to tell you that SurgeXperiences 108: Snow White and the Seven Surgeons is up over at Aggravated D0c Surg. He has done a wonderful job! Head on over for some good reads. Don't forget to "whistle while you work".

Next up for SurgeXperiences is the Monash Medical Student, who will host on November 25th. Get your posts lined up by the 23rd!

Things Happen

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

I had a visit from an old high school teacher earlier this week. She (Mrs. R) just dropped by to say hello. She was in the building anyway. Luckily I wasn't busy at the time, so we sat and chatted. Mostly she chatted and I listened. Retirement has not turned out the way she had hoped it would. She is in good health, but her dear husband of 50 years is not. He has severe Parkinson's Disease. She is such a sweet woman, no bitterness to her at all, as she lovingly takes care of him.

She needed to tell me that she had almost lost him yesterday. He was sitting at the kitchen counter while she cleaned. It had been a frustrating morning, as she had not been able to get him to eat or drink much. So she had changed gears and was just talking and singing to him while she cleaned. Then she noticed that his mouth "looked funny". When she checked, he was missing his upper partial plate. The bottom one was still in place. He looked okay otherwise. She looked around and couldn't find it on the counter, in his lap, or on the floor. (photo credit)

Then he began to make a funny noise, so she checked his mouth again and saw it lodged at the back of his mouth in his throat. She had never thought about him swallowing it, "The denture it is so big". But there it was and she couldn't get him to cough it out. She couldn't get a good hold on it with her fingers. She took me through all the ways she had tried--"I even got my kitchen tongs, but they were too large." He was breathing okay, so she tried to call for help. First, her son-in-law, but he wasn't home. Then her sister, she was and came. So while her sister helps keep Mr R's hands down, Mrs R tries again. This time she took the lower plate out which gave her more room. Then she noticed that she hit his gag reflex with her finger and that made him cough and gag. So she did it again and finally got hold of the partial plate.

Mrs R and her sister then sat back, limp. The fear hit them. The fear of what could have happened.

I looked through the instruments in my office and sent her home with the only one I had that could be of help--a 6 inch Allis Forcep (photo credit)

I think maybe the most important thing to remember when something like this happens is:

• Is your loved one still moving air well? If yes, then take a big breath of your own.
• Call 911
• IF you can easily reach the object, remove it.
• IF you can't easily reach the object or your loved one begins to have difficulty breathing (obstructed airway), then try the Heimlich Maneuver while waiting for help.

Mrs R was lucky the gag reflex helped her by making Mr R cough and "pushed" the denture forward. She could have accidentally pushed it farther back into the throat with no help on the way.

Tendon Transfers for Ulnar Nerve Palsy

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

An injury to the ulnar nerve at or near wrist or base of palm will result in paralysis of hypothenar muscles, all interosseous muscles, 1/2 of flexor pollicus brevis (FPB), the palmaris brevis, & adductor pollicis. There are some patients who will still have some intrinsic muscle function due to the martin gruber communication between the anterior interosseous branch of the median nerve (AIN) and the ulnar nerve. This occurs in 10-15% of people.

The main deficiencies are

• Sensory loss--includes the ulnar half of the ring and entire volar (palm) little finger. This surface area is important in protecting your hand as it is the surface that is rested upon a table or reached over a hot surface.
• Loss of active digital abduction/adduction -- results from paralysis of the four dorsal interossei, three volar interosse, and abductor digiti quinti (the intrinsic muscles of the hand)
• Deformity

1. Claw (Duchenne's sign)--photo credit is less severe in a high ulnar nerve palsy with the absence or defieciency of the FDP flexor tone/pull. It is more significant in low ulnar palsy and in ligamentously lax individuals.
2. Flattening of the metacarpal arch (Masse's sign)
3. Pinch collapse--either Froment's sign (IP flexion) which is when the patient attempts to pinch with the thumb and index finger, the long flexor of the thumb is used to substitute for the thumb adductor, resulting in flexion of the thumb at the interphalangeal joint (photo credit) or Jeanne's sign (MP hyperextension)
4. Abducted little finger (Wartenburg's sign)

• Dyskinetic finger flexion--With loss of the intrinsic muscles, the metacarpophalangeal joints of the ring and little fingers can only be flexed after flexion of the distal joints using the digital flexors. This reduces greatly the power of the grasp.
• Loss of power grasp and pinch

Conclusions regarding treatment, according to Hastings and Davidson, "Tendon transfers for correction of clawing deformity in ulnar nerve palsy are only consistently successful in young ligamentously lax individuals. Correction of deformity is most inconsistent in the intrinsically stiff hands of older individuals. Correction of clawing is more difficult in the little finger than in the ring finger. While use of the flexor digitorum superficialis for intrinsic transfer simply corrects clawing deformity and restores synchronous finger flexion, grip strength will be further decreased by approximately 21 percent, and total active range of motion by 7 percent. Correction is best achieved by transfer of a wrist motor with tendon graft into index, middle, ring, and little digits, despite limitation of clawing to the ring and little digits. Pinch should be augmented by metacarpophalangeal joint fusion rather than by interphalangeal joint fusion. When combined with extensor carpi radialis brevis adductor plasty, pinch strength can be doubled." photo credit

Table of options from Hastings and Davidson

Low Ulnar Palsy	Ideal	Limited
Integrated finger flexion Clawing Power Grasp	ECRB and graft or FCR and graft transferred to index, middle, ring, little proximal phalanges	FDS from middle finger transferred to the ring and little A1 or A2 pulley
Pinch	MCP joint fusion EXRB and graft through 2nd and 3rd metacarpal interspace into adductor pollicis tendon	MCP joint fusion
Digital abduction /adduction (optional)	EPB transferred into the 1st dorsal interosseous
High Ulnar Palsy
Integrated finger flexion Clawing Power Grasp	ECRB and graft to the index, middle, ring, and little proximal phalanges
Pinch	Brachioradialis adductor-plasty through 2nd-3rd metacarpal interspace to the adductor pollicis tendon MCP joint fusion
Finger flexion	Side-to-side FDP middle to FDP ring and little
Digital abduction /adduction (optional)	EPB to the 1st dorsal interosseous

References
Tendon Transfer Principles and Mechanics by Premal Sanghavi, MD --eMedicine Article
Low Ulnar Nerve Injury--Wheeless' Orthopaedic Online Textbook
Tendon transfers for ulnar nerve palsy; H. Hastings and S. Davidson; Hand Clinics, Vol 4(2) 1988, p 167-178.
Burkhalter Transfer for Claw Deformity--Wheeless' Orthopaedic
Ulnar Nerve Injury from patient's viewpoint-- Heather Gold's blog

Tendon Transfers for Pure Median Nerve Palsy

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

Low Median Nerve Palsy

When the median nerve is injured at the wrist level, there are often tendon injuries at the same time to complicate the picture. In any median nerve injury there is sensory loss that affects the important sensitive areas of the volar (palm-side) surfaces of the thumb and index finger (used to pick up objects). Transfer of islands of sensitive skin should be planned and done prior to tendon transfer so that scarring doesn't make mobilization of the neurovascular bundles more difficult.

In a pure median palsy the deficits are:

• Loss of the abductor pollicis brevis (APB)
• Loss of the opponens of the thumb

The adductor muscles are normal. A new tendon will be needed which abducts and pronated the thumb. An opponensplasty will be needed. Burkhalter in 1973 describe transferring the EIP (extensor indexus pollicus) to the APB, which is the most common transfer (photo credit). The advantages of this transfer include no requirement for a pulley or tendon graft, no loss of grasp force, and avoidance of dissection in scarred tissue. The disadvantage is that the length of the EIP is just enough to transfer to the APB. When the EIP is mobilized, the extensor hood overlying the index finger should be repaired to prevent an extension lag.

A flexor sublimis tendon is another option for this transfer as it is long enough to reach its new insertion without a graft (Bunnell opponensplasty). The ring FDS is divided at its insertion and passed around the ulnar border of the palmar aponeurosis. A pulley can be created from the FCU or PL. This transfer cannot be used in a high median nerve injury because the ring FDS is paralyzed.

High Median Nerve Palsy
This is a very disabling condition.
Deficits:

• Loss of index and long finger flexion
• Loss of wrist flexors
• Loss of forearm pronation
• Loss of thumb flexion
• Sensory Loss

It is important to prevent long term contractures. The adduction contractures can be prevented with an opponens splint. A fixed supination deformity may develop despite bracing due to the strong deforming forces of the Extensor Pollicus Longus and adductor.

Some options for restoration of function:

• There is almost complete loss of grasp except in the ring and little fingers. If the ulnar-supplied half of the profundus (FDP)is strong and active, the profundus tendons of the index and long fingers can be connected to the tendons of the ring and little finger in the forearm, proximal to the wrist using a side to side repair. This will allow the ulnar-supplied profundus to flex all four fingers. If needed, the FDP of index & long fingers may be reinforced by transfer of extensor carpi radialis longus (ECRL) to give them more strength. (photo credit)
• To balance the wrist flexion, the flexor carpi ulnaris (FCU) tendon can be split and attached half to the flexor carpi radialis (FCR) and half to its own FCU insertion.
• The thumb flexion can be restored by using the ECRL can be detaches at its insertion, pulled out halfway up the forearm, and tunneled anteriorly to be anastomosed to the flexor pollicis longus (FPL). Alternatively, the FPL can be reinforced by using the Brachioradialis.
• Abduction of the thumb can be restored using the extensor carpi ulnaris (ECU). The ECU is brought around the ulnar side of the forearm and extended by means of a free graft. This will also help with pronation of the forearm. Other options include the Burkhalter (as above) EIP to the APB

Sometimes it is necessary to include either arthrodesis of the MP joint or the distal IP joint of the thumb, depending of the stability.

The basic concept to remember in tendon transfer surgery, as advocated by Brand, is achieving balance in the extremity. Balance surpasses strength. One must strive to achieve equality in the distribution of forces, relocation, and replacement of tendons.

References
Tendon Transfers by Linda L Zeineh, MD--eMedicine Article
Tendon Transfer Principles and Mechanics by Premal Sanghavi, MD --eMedicine Article
High Median Nerve Lesions--Wheeless' Orthopaedics Online
Tendon Transfers for Low Median Nerve Lesions: Camitiz Procedure--Wheeless' Orthopaedics Online
Atlas of Hand Surgery By Sigurd Pechlaner--Google eBooks

Veteran's Day 2007

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

Thank you to all who serve or have served.

This includes my brother-in-law, Major Bart Herndon,

who is an Army Chaplain currently stationed at Ft Sill, OK

For more information on Veteran's Day (photo credit)

you can click here.

Second Travel Wallet

I finished the second travel wallet today. You can see the pictures of the first one here. This one I altered (Husqvarna pattern) slightly and used "salvaged" parts (the card slots and closure/flaps) from an old wallet. I also added a chain strap to this one and a key hook. I like this one best.

Mushrooms

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

On my walk with my dog Rusty this morning, I ran across this decaying log just covered in mushrooms. It's the first log I've ever seen like this. I just want to share this amazing site!

I don't even want to begin to "educate" you as to which wild mushrooms are edible, but I think I did identify these. They look like the picture found here (ID 50). If so they are :

"This mushroom, almost certainly, is Hypholoma fasciculae (the Sulfur Tuft). It is also known as the Clustered Woodlover, and sometimes by Naematoloma fasciculare. It has features as seen in the picture, plus: it's cap is not sticky or slimy. the gills are yellow to greenish-yellow while young and become gray or purplish-black with age, thin stalk (yellow), spores are a deep dark purple/gray/brown and is growing from wood (buried or otherwise). THIS SPECIES IS POISONOUS- do not eat. There is a similar species, but grows only on conifers (Hypholoma capnoides) and it is edible. However, do not eat either of these mushrooms without a thorough knowledge of mushroom identification and practice doing so with the supervision of an experienced mycologist/mushroom hunter."

References

Edible and Poisonous Mushrooms--MCD online

Wild Mushrooms--Ohio State University Extension Fact Sheet

Tendon Transfers Used in Radial Nerve Palsy

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

Following high radial nerve paralysis

• the wrist needs an extensor (photo credit)
• the fingers and thumb need extensors
• the carpometacarpal joint of the thumb needs an extensor to replace the abductor pollicis longus

Most authors agree that tendon transfers provide good results if nerve reconstruction fails in patients with radial nerve palsy. There is continued disagreement on the best combination of tendon transfers to use in treating patients with radial nerve paralysis. The level of the radial nerve injury and a patient’s overall function and anatomy should be kept in mind when choosing the best surgical option available for that patient.

In 1916, Robert Jones described a tendon transfer for radial nerve palsy that included the pronator teres to the wrist radial extensors, the flexor carpi radialis to the extensors comminis, and the flexor carpi ulnaris to extensor indicis and pollicis longus. The transfer of both wrist flexors has since been abandoned by most surgeons because of the excess morbidity from the loss in wrist flexion.

Most authors agree that the extensor carpi radialis brevis and longus should be reconstructed using the pronator teres tendon. This transfer is so effective that it is often done at the time of nerve repair. It provides good wrist stability for power grip, making the hand useful even during the recovery period. Try flexing your wrist and then keeping your wrist flexed while trying to make a fist, as you would in a power grip to open a jar, etc. It is very difficult, almost impossible to have a true power grip without wrist extension or neutral position. (photo credit)

To provide extension for the fingers, it is best to use a wrist flexor as this is synergistic with finger extension. At one time it was common to transfer all wrist flexors in the case of radial palsy, but Zachary pointed out the need to keep stability on the flexor side too. Boyes emphasized the importance of keeping the flexor ulnaris in its position to give the important movement of ulnar deviation. There is no one "great" transfer here. The extensor digitorum communis can be reconstructed using the flexor digitorum superficialis (III), the flexor carpi ulnaris, or the flexor carpi radialis. The rerouted extensor pollicis longus can be reconstructed using the palmaris longus or the flexor digitorum superficialis (IV), and, in some cases, the abductor pollicis longus and extensor pollicis brevis can be reconstructed with the flexor carpi radialis. Dr. Susan MacKinnon prefers to use the pronator teres to the extensor carpi radialis brevis, the flexor carpi ulnaris to the extensor digitorum communis, and the palmaris longus rerouted to the extensor pollicis longus (when available); otherwise, we use the flexor digitorum superficialis. (photo credit)

Burkhalter also advocated early tendon transfer because he believed the transfer acts both as a substitute during regrowth of the nerve or when lesions are irreparable and also as a helper during reinnervation. In a recent article, Kruft et al. reported that irreversible radial nerve paralysis should be treated with early tendon transfer. They reported 43 patients who underwent tendon transfer, with 38 patients ultimately returning to their original jobs. The authors qualified their results by stating that tendon transfers “never fully replace an intact radial nerve for the purpose of controlling the hand.” Elton and Omer observed that patients with radial nerve paralysis treated by tendon transfer often experienced extensor tightness, which prevented simultaneous flexion of the wrist and fingers. Barton described this as a “rather unnatural movement, seldom needed in ordinary life.” Many authors have thought that the greatest functional loss after radial nerve palsy was not the loss of finger extension, but instead the loss of power grip, which cannot be easily recreated with standard tendon transfers.

References
Current Approach to Radial Nerve Paralysis; Plastic & Reconstructive Surgery. 110(4):1099-1113, September 15, 2002; Lowe, James B. III, M.D.; Sen, Subhro K. M.D.; Mackinnon, Susan E. M.D.
Tendon Transfers for Radial Nerve Palsy-- Wheeless' Online Textbook of Orthopaedics
Atlas of Hand Surgery By Sigurd Pechlaner--Google eBook (very nice pictures of the transfers)
The Hand: Fundamentals of Therapy By Judith Boscheinen-Morrin, W. Bruce Conolly--Google eBook
Radial Nerve Entrapment by Mark Stern, MD--eMedicine article

Tendon Transfer--General Principles

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

Tendon transfers are done to restore a function that has been lost. It is a procedure in which the tendon of a functioning muscle is detached or divided at or near it's insertion, mobilized and reinserted into a bony part or another tendon to supplement or substitute for the lost function. Restoring something as simple as a pinch grip can create major improvement in the function of the hand. (photo credit)

Tendon transfers have been used in upper extremity reconstruction for well over a century. Early on, the technique was used for reconstruction following obstetric brachial plexus palsy or paralysis secondary to polio. As hand surgery evolved as a subspecialty, transfer techniques expanded. The middle part of the 20th century saw the development of transfers for multiple peripheral nerve paralyses, including median, ulnar, and radial nerve palsies. Some of the "Giants" who contributed to the field, include Bunnell, Boyes, Brand, Burkhalter, Goldner, Littler, Moberg, Omer, Phalen, Riordan, and Zancolli.

Indications for tendon transfers

• Irreparable nerve damage --Penetrating injuries can result in transection of the median, ulnar, or radial nerves or more centrally in the brachial plexus.
• Loss of function of a musculotendinous unit due to trauma or disease -- Rupture of the extensor pollicis longus (EPL) tendon is a common complication secondary to a distal radial fracture. Rheumatoid arthritis may be responsible for tendon rupture of any of the hand and wrist tendons, but it commonly leads to rupture of extensor tendons of the fingers or thumb (photo credit).
• In some non-progressive or slowly progressive neurological disorders -- These tends to be less responsive to surgical solutions, and can include stroke and neurologic diseases such as multiple sclerosis or cerebral palsy.

Contraindications:

• The only absolute contraindication to tendon transfer is a lack of appropriate donors.
• The availability of muscle-tendon units with less than grade 5 strength is a relative contraindication.
• Similarly, if only muscles that have been denervated and then reinnervated are available, this is also a relative contraindication.
• Transfers planned in individuals with progressive neuromuscular diseases should be carefully considered before proceeding because the underlying disease process may affect the transferred unit.
• Lastly, satisfactory results are difficult to achieve in transfers performed to produce motion in less-than-supple joints.

Most important functions of the Upper Extremity

Grasp power (FDP & wrist stabilisers)
Pinch (FDP, FDS & intrinsics)
Positioning the hand

Radial nerve injuries affect opening the hand for grasping. Low ulna and median nerve defects affect surrounding the object to grasp.
High ulna and median nerve injuries affect long flexors and grip

Axillary palsy and brachial plexus palsy -- unable to abduct the shoulder and here shoulder arthrodesis may be indicated to stabilise the upper arm to enable effective use of distal muscles. (generally transfers around the shoulder of little value)

Elbow function dependant on the musculocutaneous nerve. Pectoralis major transfer to biceps (Clark), proximal transfer of the common flexor origin (Steindler), triceps transfer (Bunnell) and may restore elbow flexion. Latissimus dorsi can also be used to restore elbow flexion.

Key elements crucial in tendon transfer operations.

• Be sure that the tendon to be transferred can be spared from it's original location. The EIP has redundant function with the EDC and, thus, is expendable. Before transfer of the EIP, especially in a patient with rheumatoid arthritis, the surgeon should be confident that the EDC has not been affected by the disease and is functioning normally.
• Be sure that it is strong enough for its new task. Only muscles with power of 4+ should be considered donors as they always lose 1 MRC grade of power.
• Be sure it has enough amplitude for its movement. As a guide, amplitudes are as follows: Wrist motors 33mm; Finger extensors 50mm; Finger flexors 70mm.
• Be sure that is is under conscious voluntary control
• Be sure that its old action is synergistic with its new, or at least retrainable to it (photo credit--example of natural synergic movement: The effect shows extension of the fingers when the wrist is flexed and flexion of the fingers when the wrist is extended. If the tendons are not intact, this effect is lost.)
• Be sure that it can reach its new insertion without a sharp change of direction
• Be sure that it can get to its new location without going through dense scar tissue, through fascia, or across bare bone
• Be sure that the movement it is expected to produce is already freely possible by passive movement (no stiff or "frozen" joints)
• Be sure that they patient understands what is to be done and is ready to accept the postoperative discipline of exercises and training

Timing

The timing of a tendon transfer after an injury depends on the likelihood of spontaneous reinnervation and nerve recovery. If nerve repairs or nerve transfers were performed initially, then sufficient time has to be allowed to determine the outcome of the initial treatment before considering tendon transfers. Keep in mind that axons regenerate at a rate of approximately 1 mm per day. If one cannot determine from the initial injury whether the nerve was interrupted (neurotmesis) and if the clinical examination reveals a loss of motor or sensory function, determining if adequate recovery is likely is mandatory before considering tendon transfer as a reconstructive option. EMG performed immediately and then again at 6 weeks helps to determine which functions may be expected to recover. Lack of evidence of innervation at 6 weeks should prompt exploration and repair if possible. Once sufficient time has elapsed to allow for spontaneous or repaired recovery, consider reconstruction for missing functions. (photo of some splints often used in upper limb paralysis--credit)

Of note, some hand surgeons advocate early tendon transfers, particularly in patients with radial nerve palsies, even if recovery is still possible. In 1974, Burkhalter reported that the indications are

(1) the transfer can act as a substitute during regrowth of the nerve, which will thereby reduce the time of external splinting and improve early function
(2) the transfer can act as a helper and add power to normal reinnervated muscle function
(3) the transfer can act as a substitute when, statistically, the recovery after neurorrhaphy or nerve repair is poor.
References
Tendon Transfer Surgery--American Society for Surgery of the Hand
Hand, Tendon Transfers by Philip E Higgs, MD--eMedicine article
Tendon Transfer Principles and Mechanics by Premal Sanghavi, MD and Mohammad Ali, MD--eMedicine article
Surgical Reconstruction and Rehabilitation in Leprosy and other Neuropathies by Richard Schwarz, MD
Peripheral Nerve Problems --Military Report by Colonel George E. Omer, Jr., MC, USA (Ret.), and Colonel William W Eversmann, Jr., MC, USA (Ret.)

Paul Brand, MD (1914-2003)

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

There is a wonderful essay on pain, "Pain and Suffering", written by T over at her blog, Notes of an Anesthesioboist. Emilyoboe left a comment "have you read The Gift of Pain (alternately titled Pain: the Gift No One Wants) by Paul Brand and Philip Yancey? I think you might enjoy it, it relates a lot to what you're also saying about pain." These were my source of inspiration for this post. (photo credit)

I actually got to meet this wonderful man, Dr. Paul Brand. I was in such awe that I could hardly speak. I was doing a Flexible Internship at Earl K Long Hospital in Baton Rouge, Louisiana. They allowed me to do a hand surgery rotation with Dr. Ronnie Matthews. He was a friend (and student) of Dr. Brand's. He took me with him when he went to Carville to watch the two of them do some tendon transfer surgeries and see patients in the clinic there. Carville was the location of the US Public Service Hospital for Hansen's Disease patients. For over a century, from 1894 until 1999, Carville was the site of the only in-patient hospital in the continental United States for the treatment of Hansen's disease, the preferred designation for leprosy. It is now the site of the National Hansen's Disease Museum (photo credit and website link).

Dr. Paul Brand was born to missionary parents (Jesse and Evelyn "Granny" Brand) and lived in Southern India until he was sent home at age 9 yrs to the United Kingdom for education. His father died in 1928 of malaria after Paul's return to the UK in 1923. Dr. Brand trained in Medicine at University College Hospital during the Second World War, and later gained his surgical qualifications while working as a casualty surgeon in the London Blitz. He meet his wife Margaret while at medical school. She was an ophthalmologist.

In 1946, he was invited to join the staff of the Christian Medical College & Hospital in Vellore, India. It was in India that the Brands first came across "leprosy beggars", deformed, blind and crippled by the disease. Deeply affected by the acute anguish and isolation of people afflicted with leprosy, he and his wife dedicated themselves to relieving their suffering.

After a visit to the Leprosy Sanatorium at Chingleput, Dr. Brand was motivated to explore the reasons for the deformities developed in those with Hansen's Disease. Through his research in South India, Dr Brand forever changed the world’s perceptions and treatments of leprosy-affected people:

• First, he pioneered the then startling idea that the loss of fingers and toes in leprosy was due entirely to infection and was thus preventable. Because leprosy attacks chiefly the nervous system, resultant tissue abuse occurs because the patient loses the warnings of pain – not because of inherent decay brought on by the disease. Paul Brand discovered the gift of pain, claiming that because leprosy destroyed the sensation of pain in affected parts of the body, pain-deprived people inadvertently injured and destroyed themselves.
• Second, as a skilled and inventive hand surgeon, he pioneered tendon transfer techniques with leprosy patients, and opened up a whole new world of disability prevention and rehabilitation for the most vulnerable and helpless in society.

In the late 1940s, he became the first surgeon in the world to use reconstructive surgery to correct the deformities of leprosy in the hands and feet. His wife Dr. Margaret Brand devoted herself to researching methods to prevent blindness in persons with leprosy. Later, Dr. Paul Brand was able to apply similar techniques to treat the limbs of persons with diabetes, as both diseases destroy pain sensation.

In 1950, with a donation from a missionary woman, Dr. Brand established the New Life Center, Vellore, as a model rehabilitation center for Hansen's Disease patients. The center was a village environment located at the residential area of the Christian Medical College campus. This helped dispel the stigma that was so prevalent even among medical professionals. Correcting deformities to restore the self-respect of patients and to integrate them into society was his cherished goal.

In 1966, he moved to the United States on invitation to take up the position of Chief of Rehabilitation Branch at the National Hansen's Disease Center at Carville. He worked there for 20 years and established a well-equipped and well-staffed research unit to study the complications of insensitive hands and feet, their prevention and management. His methods for prevention and management of plantar ulcers are now extensively used for treatment of patients with diabetes mellitus who have similar problems. Dr. Brand also popularized the technique of serial casting for the finger deformities (flexion contractures) that often result from Hansen's Disease, a technique that is now widely used by hand therapists to treat contractures due to many different hand injuries and conditions. When he retired in 1986 from the U.S. Public Health Service, he moved to Seattle and continued his teaching work as emeritus professor of Orthopedics in the University of Washington.

His appreciation of the importance and value of pain is well described in his book Pain: The Gift Nobody Wants. He saw pain as vital for the preservation of healthy tissue in anyone leading a normal life and he gives horrifying descriptions of the results of insensitivity in those with Hansen's Disease or congenital absence of pain. He goes on to question the pursuit of pleasure in Western Society and offers practical ways to ameliorate the effects of pain. I think I gained some of this appreciation for pain from him and his book. I don't (except in surgery) want my newly post-surgery patients to be completely pain-free while healing. I want them to use that pain to protect themselves from over-activity. I want to ease their post-surgery pain, not erase it.

References
THE LEPROSY MISSION, A Legend has passed into history Dr Paul Wilson Brand - 1914-2003 Obituary by Ms Janet Walmsley
Dr Paul Wilson Brand – 1914-2003; An Extraordinary, Gifted Orthopaedic Surgeon who Straightened Crooked Hands and Unravelled the Riddle of Leprosy
Dr. Frank Duerksen, a Leprosy Surgeon--an interview, influenced by Dr. Paul Brand

Travel Wallet and Toddler Quilt

I finished one of the travel wallets for my sister and her daughter. It turned out okay, but I think I will make the closure strip wider on the next and tweak the sections for cards (drivers license, credit card, etc). They received their passports just eleven days after applying for them. They are so excited about their trip to New Zealand.

Spent most of my time this past weekend working on a quilt for a toddler with cancer. He is undergoing chemotherapy. I did one of my "crazy" quilts. I hope it will help provide not only warmth in cold hospital rooms, but distraction as he searches for horses, trucks, monkeys, fish, bears, pumpkins, Elvis, dogs, colors and shapes, etc in the quilt. I am using the "clam shell" pattern for the actually quilting.

Find the truck, cowgirl, mitten, Santa, woman, horse, reindeer.

Find the zebra, mitten, fireworks.

Find Elvis, Winne the Pooh & Piglet, pumpkin, Air Man, dragonfly, sheep.

Find the monkey, sheep, bears.

Find the dog, fish, polka dots, checks.

Find the heart, pumpkin, flowers, truck, dog.

Inverted Nipples

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

As many as 2-10% of American women have at least one inverted nipple. Most cases of inverted nipples are congenital - some people are just born that way. However, some nipples become inverted after breastfeeding when scar tissue builds in the milk ducts. The anatomic defect lies in the relative shortness of the lactiferous ducts, which tether the nipple and prevent it from projecting. (photo credit)

There are different degrees or grades of nipple inversion.

• Grade 1: The inverted nipple is easily pulled out, maintains its projection fairly well without traction. Gentle finger pressure around the areola or gently pinching the skin causes the nipple to pop back out. It is believed to have minimal or no fibrosis. There is no soft-tissue deficiency of the nipple. The lactiferous duct should be normal without any retraction (photo)
• Grade 2: The inverted nipple can be pulled out, but not as easily as in Grade I. After releasing traction, the nipple tends to fall back and invert again. Grade II nipples have a moderate degree of fibrosis. The lactiferous ducts are mildly retracted but do not need to be cut for the release of fibrosis. On histologic examination, these nipples have rich collagenous stromata with numerous bundles of smooth muscle. Most inverted nipple will fall into this category. (photo)
• Grade 3: The nipple is severely inverted and retracted. It is very difficult to pull out these nipples manually. Despite application of pressure on the nipple to force it to protrude, it promptly retracts. A traction suture is needed to hold these nipples protruded. The fibrosis is remarkable and lactiferous ducts are short and severely retracted. The bulk of soft tissue is markedly insufficient in the nipple. Histologically, there are atrophic terminal duct lobular units and severe fibrosis.

Surgical Correction of Inverted Nipples

Correction for inverted nipples can be done on an out-patient basis. A patient may opt for local anesthesia, intravenous sedation and local anesthesia, or general anesthesia. Several different techniques have been developed and currently are in use for correction of the inverted nipple. The diversity of techniques indicates the lack of a good, sustainable, and durable solution for this quite common problem. (sketch is from the 2nd article)

Grade I--a non-incisional, purse-string suture technique

• The nipple is popped out manually. A small vertical incision (2 to 3 mm) is made at the 6 o'clock position at the base of the nipple. By using 5-0 nylon with a straightened needle, a purse-string suture is placed around the neck of the nipple. The knot is buried under the skin. One stitch is enough to close the skin

Grade II--will require a technique that releases the fibrosis and a purse-string suture

• The nipple is pulled out manually, and a 4-0 nylon traction suture is used for easy handling. An incision is made at the 6 o'clock position and deepened to the breast parenchyma. The fibrous tissues are released in the vertical direction by using scissors, and all lactiferous ducts are identified and preserved. Fibrosis is released to a degree that the nipple can maintain its projection without any traction (this is very important). An intradermal purse-string suture is done by using 5-0 nylon. Care should be taken not to apply too much force, which could compromise the blood supply of the nipple.

Grade III--requires a technique that releases the fibrosis, often the ducts will need to be cut, dermal flaps will be needed along with the purse-string suture

• The nipple is pulled out forcibly by using a traction suture. The neck of the nipple is marked. Two or three deepithelialized flaps are elevated at the 10, 2, and 6 o'clock positions. The deepithelialized dermal flap is bigger than the skin excision. The tissue beneath the nipple is dissected, and the fibrosis is released. The retracting lactiferous ducts are cut mainly from the central portion of the nipple. All the fibrosis and retracting ducts are released until the nipple can maintain its eversion by itself without any traction. The dermal flaps are turned down through the tunnel and sutured together to give bulkiness to the nipple. A 5-0 buried purse-string suture is placed at the base of the nipple. The newly everted nipple is maintained by a sombrero splint in place with sutures for 1 week to keep the nipple projection. (diagram is from 4th article--modified Namba technique)

Recently (see 3rd reference article) a technique using nipple piercing has been described. It is worth considering in Grade I and II inverted nipples. The authors suggest trying it in Grade III also, and maybe it is worthwhile when you consider that bone length can be achieved with distraction therapy. If the patient would gently tug on the nipple ring each day, the duct/skin can often be stretched.

Correction using Nipple Piercing

• With the patient in a sitting position, an entrance and exit point is marked on the nipple base in either horizontal or vertical plane, depending on the patients’ preference. Then with the patient in the supine position, the nipple is prepared with Betadine. Local, may or may not be used. A usual piercing technique was used. A 14-gauge needle was passed horizontally through the base of the nipple. A 5/8 -inch stainless steel nipple ring is advanced following the needle and through the tract. The procedure is completed within seconds. No local anesthetic is used. The nipple ring is cleaned daily. At 4-6-month follow-up the nipple ring is removed. (photo credit)

Risks of Surgical Correction:

The most dreadful complication can be compromise of blood supply to the nipple caused by dissection of fibrosis and a strong, tight purse-string suture. This complication is more likely in grades II and III, for which retraction is more severe. Other complication/risks include re-inversion, infection, tissue injury, excessive bleeding, and adverse reaction to anesthesia. The procedure may also result in noticeable scars, permanent pigment changes, or slightly mismatched nipples. Nipple protrusion with stimulation may change. If nipple inversion recurs or asymmetry is significant, a second procedure may be needed. The temporary effects of inverted nipple surgery can include loss of breast sensation or numbness. There is no guarantee that breast feeding will be possible after correction of inverted nipples.

References

Simple Technique for Inverted Nipple Correction; Morris Ritz, Ram Silfen, David Morgan and Graeme Southwick ; Aesthetic Plastic Surgery Journ, Vol 29, No 1, pp 24-27

The Inverted Nipple: Its Grading and Surgical Correction; Plastic & Reconstructive Surgery. 104(2):389-395, August 1999; Han, Sanghoon M.D.; Hong, Yoon Gi M.D.

A Contemporary Correction of Inverted Nipples; Plastic & Reconstructive Surgery. 107(2):511-513, February 2001; Scholten, Erik Ph.D.

Surgical Correction of Inverted Nipples Using the Modified Namba or Teimourian Technique; Plastic & Reconstructive Surgery. 113(1):328-336, January 2004; Lee, Kyung Young M.D.; Cho, Byung Chae M.D.

Pictures of Correction Surgery (some may consider them graphic)

SurgeXperiences 108

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

SurgeXperiences 108 will be up on 11 Nov at Aggravated DocSurg. Please submit any surgical-related articles via this page. I would encourage contributions from surgeons, nurses, anesthesia folks, students, and patients alike. Any experiences related to surgery are welcome. (photo credit)

Perioperative Corticosteroid Coverage

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

I have a patient who has been treated long term with a low dose of corticosteroids for her arthritis. She wants to have an abdominoplasty early next year. She is healthy otherwise and is a nonsmoker. I will remove slightly less skin than I would have so there is less tension on her incision, but if she will work with me things will go well. I told her she and I would need to discuss her steroid use perioperative, and that her steroid use may delay her healing. More important to me is the possibility of an impaired response to the stress of surgery and anesthesia. This can happen due to the suppression of hypothalamic-pituitary-adrenal axis (adrenal insufficiency) that happens with prolonged corticosteriod use. (photo credit)

I was taught the following (first reference):


In-patient surgery

• Methylprednisone (Solu-Medrol) 20 mg IM on call to surgery


• During surgery infuse hyprocortisone (Solu-Cortef) 100 mg IV over 8 hr


• Day of surgery: hydrocortisone 50-100 mg IV every 8 hr


• POD #1: hydrocortisone 25-50 mg IV every 8 hr


• POD #2: hydrocortisone 25 mg IV every 8-12 hr


• Thereafter: Resume maintenance steroid dose if there are no complications which prolong stressful period, for example, infection.

Out-patient surgery

• Methylprednisolone 20 mg IM on call to surgery


• During surgery infuse hydrocortisone 50 mg IV over 4 hr


• Evening of surgery give double usual daily dose of prednisone


• POD #1: Resume maintenance therapy


• IV fluids should contain saline

I was pleasantly surprised to see that a fellow blogger, Notes from Dr. RW, recently posted on just this subject. He covered the subject from the hospitalist point-of-view. Here is his summary of current recommendations:

Minor procedure (endoscopy, inguinal hernia repair):

• 25 mg hydrocortisone or its equivalent on day of procedure only.

Moderate procedure (abdominal surgery):

• 50-75mg hydrocortisone on day of procedure and taper quickly over 2-3 days to patient’s maintenance dose.

High risk procedure (cardiovascular surgery, extensive abdominal):

• 100-150 mg hydrocortisone initially, then taper over 1-2 days to patient’s maintenance dose.

It is important for all of us (surgeons, anesthesiologist, internist, etc) to remember how long term use of prednisone can affect patients.


References
Hand Clinics--Rheumatoid Arthritis; chief editor Paul Feldon, MD; May 1989;page 119
Perioperative Management of the Rheumatic Disease Patient; Joe T. Kelley III, MD, Doyt L. Conn, MD; Bulletin on the Rheumatic Diseases, Vol 51, No 6 (free access on-line)
Corticosteroid Supplementation for Adrenal Insufficiency; Douglas B. Coursin, MD; Kenneth E. Wood, DO ; JAMA, 2002;287:236-240
What is Adrenal Insufficiency?--EndocrineSurgeon