SurgeXperience 118 is Up!

 Updated 3/2017-- all links removed as many no longer active as it was easier than checking each one.

The 18th edition of SurgeXperiences, hosted by by the guys at OpNotes is up!  They called it -- "Need a second opinion?"  It is worth reading. I hope you will check it out.

The 19th edition will be hosted by  (needed). The deadline for submissions will be March 14th. Start writing and submitting here!

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here

Happy Doctor's Day!

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active as it was easier than checking each one.


History of Doctor's Day

The first Doctor's Day observance was held on March 30, 1933, by the Barrow County Alliance, in Winder, Georgia. Eudora B Almond, the wife of Dr Charles B Almond, conceived the idea of setting aside a day to honor physicians. The day set for the recognition occurred on the anniversary of the first administration of anesthesia by Dr. Crawford W. Long in Barrow County, Georgia, in 1842.

This first observance included the mailing cards to the physicians and their wives, placing flowers on graves of deceased doctors, and a formal dinner in the home of Dr. and Mrs. William T. Randolph.

The full history of how it went from a locally observed day (1933) to a national observed day (1990) can be found here.
Through the years the red carnation has been used as the symbol of Doctors' Day.
Meanings of the Carnation Flower : Fascination, devoted Love
Deep Red Carnation : My heart aches for you or I admire you

Happy Doctor's Day to all of you!

Lawn Mower Safety

 Updated 3/2017-- photos and all links removed as many no longer active as it was easier than checking each one.

Last weekend I got our lawn mower out. The "weeds" more than the grass had grown high enough to need mowing. I put gas in, changed the air filter, but could not get the spark plug changed. It would not budge. Being one of those independent females, having to wait for my husband (who was out of town) to get home and do the lawn mower maintenance for me is frustrating. (Of course, it would have been nice for him to do it before he went out of town.) My father-in-law suggested I "soak" it with WD-40 overnight. It worked. So Thursday I got the spark plug changed and the mower started! The yard is mowed.

So in preparation of the coming mowing season, lets try to be safe this year. The power lawn mower is considered one of the most dangerous tools around the home. Did you know that lawn mower injuries alone cost the nation approximately $475 million annually in health care costs? Did you know that nearly 10,000 children in America are injured each year as the result of a lawn mower accident? Did you know that lawnmower injuries account for a large percentage of accidental partial or complete finger/toe amputations?

Lawn mower injuries include deep cuts, loss of fingers and toes, broken and dislocated bones, burns, and eye and other injuries. Some injuries are very serious. Both users of mowers and those who are nearby can be hurt.

Safety Tips

• Before operating equipment, familiarize yourself with it and make sure it is in good working order.
• Heed the manufacturer precautions.
• Be sober (i.e., don't drink).
• Use lawn mowers with guards and a cutoff switch. Never disconnect the cutoff switch.
• Exert extreme caution on slopes and never mow when the ground is damp.
• Do not allow other people, and particularly children, in the area when operating a lawn mower.
• Never allow children to ride on mowers.
• Never go barefoot while mowing. Sandals and flip-flops are no better than being barefoot.
• Wear protective eye gear, hand gear and footwear such as goggles, gloves and heavy rubber sole boots. (Hiking shoes with double wall leather and cleats are good. Golf shoes are even better.)
• Pick up toys, tree limbs, rocks, etc from the yard. Any of these things can become potential projectiles.
• Fill the gas tank while the engine is off. Never smoke when filling the gas tank.
• When a lawn mower cuts off, be extra careful in removing any objects from the blade. Always make sure the engine is off and the mower blade has completely stopped rotating before attempting to remove debris from the mower or make adjustments. It is best to disconnect the spark plug so the mower can't start while near the blade.
• Do not leave a lawnmower unattended when it is running. If you must walk away from the machine, shut off the engine.

REFERENCES
Preventing Lawn Mower Injuries; American Orthopaedic Foot and Ankle Society
Lawn Mower Safety Could Save Life and Limb This Summer; University of Michigan Health System; June 2, 2003
Lawn Mower Safety; American Academy of Pediatrics
Snowblower and Lawnmower Injuries; American Society for Surgery of the Hand
Lawn Mower Safety Tips; Briggs and Stratton
Lawn mower-related injuries to children; J Trauma. 2005; 59(3):724-8; Abstract

Amish Bars Quilt

I finally finished hand quilting this quilt. The pattern is Amish Bars. My friend asked for brown and mustard yellow (picture doesn't show the colors well--sorry). The back is a lighter brown, as I wanted the quilting to show. The brown strips are quilted with brown thread, the yellow with a light brown. You can see the quilting patterns in my post on Marking. The quilt is 52 in X 72 in. The strips are 8 in, 3 in, 6 in, 3 in, 8 in, 3 in, 6 in, 3 in, and 8 in.

I tried to show some of the quilting detail. This is the center brown strip.
The back of the quilt, showing one of the "smaller" brown strips.

Medical Leech Use

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active as it was easier than checking each one.

The leech was indispensable in 19th Century medicine for bloodletting. Bloodletting is a practice believed to be a cure for anything from headaches to gout. It is what Demi Moore recently received to "detoxify" her blood. Bloodletting was abandoned by the medical community long ago in favor of scientific medical advances.

Use of leeches underwent a renaissance of sorts in the area of modern plastic reconstructive surgery and particularly in microsurgery transplantation. Credit for this renewed interest in leeches is given to two Slovenian surgeons, M. Derganc and F. Zdravic, who described their use to prevent venous congestion of skin-flap transplants in an article in the British Journal of Plastic Surgery in 1960. These surgeons credit their own use of leeches to a Parisian surgeon, one Philippe-Frédéric, who reported in 1836 that he had used leeches to restore circulation following reconstruction of a nose.

Leeches are most following reattachment or transplantation surgery (fingers, toes, ears, etc) and in flap surgery when the venous outflow is poor -- hence venous congestion. Many flaps and reattachment fail due to venous congestion rather than the arterial blood supply. It is much easier to attach the two ends of the arteries as arteries are thick-walled and relatively easy to suture. The veins, however, are thin-walled and especially difficult to suture, especially if the tissue is badly damaged. It is not uncommon to get blood to flow in the reattached arteries but not veins. When that happens, the venous circulation is severely compromised. The blood going into (arterial) the reattached finger/flap becomes congested, or stagnant due to the poor outflow (venous). The reattached portion turns blue and lifeless and is at serious risk of being lost. This is when the leech comes in handy.

Treatment of venous congestion includes

• Removing tight dressings and sutures
• Increasing the elevation to promote venous drainage via gravity
• Leeches are effective for treating venous congestion in replantation
• Nail plate removal and the application of a heparin-soaked sponge to the nail bed has been described for distal replantations (fingers or toes) when a vein could not be repaired and the patient refused leeches (Gordon, 1985).
• Finally, operative revision can be considered. This is less successful for salvaging a failing replant because of venous congestion rather than arterial insufficiency.

So how do leeches work? The rationale behind the use of leeches in surgical procedures is fairly straightforward. The key to success is the exploitation of a unique property of the leech bite -- the creation of a puncture wound that bleeds literally for hours. The leech's saliva contains substances that

• anesthetizing the wound area (a local anesthetic substance)
• dilate the blood vessels to increase blood flow (a histamine-like vasodilator that promotes local bleeding)
• prevent the blood from clotting [1)Hirudin, a direct thrombin inhibitor and 2) Hyaluronidase, which increases the local spread of leech saliva through human tissue at the site of the wound and also has antibiotic properties]

Complications of Leech Therapy

Aeromonas hydrophila infections are a recognized complication of postoperative leech application, with reported incidences ranging from 2.4% to 20%. Prophylactic antibiotics are often recommended. In the event infection develops, early diagnosis and immediate initiation of an empirical intravenous antibiotic therapy are essential.

Another major concern in the use of leeches is their migration from the surgical site, possibly into the body or the wound itself. It has been suggested that you attach one end of a surgical suture to the leech and tie the free end to a firm object or dressing.

Leech therapy or bloodletting will not detoxify your body. Blood loss is not how the body detoxifies itself. Our bodies use the kidneys and liver for "detoxifying" or "filtering" the blood. I would politely suggest that if Demi thinks that bloodletting detoxifies her body, maybe she could donate blood so someone will truly benefit from it.

REFERENCES
Alternative Treatments for Wounds: Leeches, Maggots, and Bees; Medscape Article, Nov 8, 2007; Karen Dente, MD
Hand, Amputations and Replantation; eMedicine Article, June 28, 2006; Bradon J Wilhelmi MD
When Modern Medicine Needs Some Help - Jack McClintock (PDF file)
(Gordon L, Leitner DW, Buncke HJ, Alpert BS. Partial nail plate removal after digital replantation as an alternative method of venous drainage. J Hand Surg [Am]. May 1985;10(3):360-4. [Medline]
Salvage of Partial Facial Soft Tissue Avulsions with Medicinal Leeches; Otolaryngol Head Neck Surg, 2004; 131 (6):934-9; Frodel JL, Barth P, Wagner J (abstract)
Beyond Bloodletting: FDA Gives Leeches a Medical Makeover; FDA Consumer Magazine, Sept-Oct 2004 Issue; Carol Rados
BioPharm Leeches--a supplier who is on "the biting edge of science". Their site is full of useful information regarding applying leeches, post-leech wound care, etc.
UCLA Louise M Darling Biomedical Library; History & Special Collections--very nice online exhibit on Bloodletting

Bilobed Flap for Repair of Nose

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active as it was easier than checking each one.

There is an almost bewildering number of reconstructive options from which to select for the nose. The most common etiology of nasal defects that require reconstruction is skin cancer, particularly basal cell carcinoma (BCC) which is the most common nasal skin cancer. It also includes squamous cell carcinoma (SCC) and melanoma. There is a rich history of nasal reconstruction as mentioned in my post last summer.

For loss of skin only, there are some lovely local flaps that can be used. This includes the bilobed flap that was used to reconstruct TBTAM's nose. Some of the folks who left comments mentioned that they couldn't quite imagine "where the skin came from". I hope this helps.

The bilobed flap is designed with the long axis of the defect (near the tip of the nose in the picture). Each lobe of the flap is separated by 45° angles. The two lobes of the flap rotate together along an arc with all points on the arc equidistant from the apex of the defect. The larger lobe rotates into the initial defect created by the skin cancer removal. The second smaller lobe rotates into the defect left by the first lobe. A small "triangle" is removed along with the smaller (most superior lobe in picture) lobe so that its defect can be closed as a straight line. The skin that is moved is full thickness.

For additional flaps, check out the eMedicine article listed below.
By the way, TBTAM's nose is looking very nice.

REFERENCES
Nasal Reconstruction, Principles and Techniques: Joseph Fata MD; eMedicine Article, April 2, 2006
TBTAM's Mohs Nose Woes Photos, Part I, Part II, and Part II

Disaster Medicine and Public Health Preparedness

Updated 3/2017-- photos and all links removed as many no longer active as it was easier than checking each one.

As the floods continue to be an issue here in Arkansas and with the explosion of a meat packing plant in Booneville which required an evacuation due to an ammonia leak into the air, it seems like a good time to review some sources for information for both medical and non-medical folk. Gallery of flood pictures.

• Don't drive through rising water. It only takes 2 feet of water to carry away most cars and sport utility vehicles. The majority of drowning deaths from flash floods are related to being trapped in the motor vehicle.
• Flash flooding causes most of the fatalities due to natural disasters in the United States.
• Clean up mold and germs from the flood water. Fix any leaking pipes and other water problems and then dry things, or the mold will grow again.
• It is best to wear a respirator mask over your mouth and nose when you clean, so that you do not breathe in a lot of mold. A respirator that protects against mold is called an N-95 respirator.
• Wash your hands often and be careful of cuts and scratches. The water you wade through may be contaminated by sewage overflow or backup.

Check out these sources for more information. Be safe.

MedLine Plus -- Disaster Preparedness and Recovery. A lot of good information for citizens. The main page has many links to other agencies and articles, but these two are a good place to start.

Are You Ready? An In-Depth Guide to Citizen Preparedness(Federal Emergency Management Agency) - Links to PDF
Picking up the Pieces After a Disaster(American Red Cross)
Arkansas Department of Health--Food and Water Safety Following a Flood - opens as a PDF

CDC Emergency Preparedness and Response -- website has sections on Bioterrorism Emergencies, Chemical Emergencies, Radiation Emergencies, Mass Casualties, Natural Disasters and Severe Weather, and Recent Outbreaks and Incidents. Full of information and worth checking out.

FEMA Emergency Management Institute Independent Study Program -- The Emergency Management Institute (EMI) offers self-paced courses designed for people who have emergency management responsibilities and the general public. All are offered free-of-charge to those who qualify for enrollment. To get a complete listing of courses, click here.

Nurses on the Front Line: Preparing for and Responding to Emergencies and Disasters - hosted by The National Nurse Emergency Preparedness Initiative (NNEPI), developed by The George Washington University Department of Nursing Education and funded by The U.S. Department of Homeland Security.

Johns Hopkins Center for Public Health Preparedness Online Training Modules -- training modules on the following emergency preparedness and response topics: Agriculture, Food and Water; Chemical, Biological, Radiological, Nuclear Terror; Infectious Disease and Vaccines; Legal Issues; Mental Health Preparedness; and General Public Health Preparedness

WISER is a system designed to assist first responders in hazardous material incidents. WISER provides a wide range of information on hazardous substances, including substance identification support, physical characteristics, human health information, and containment and suppression advice. Free download available as a stand-alone application on Windows Mobile devices, Palm OS PDAs, and Microsoft Windows PCs.

Face Transplant

Updated 3/2017-- photos and all links removed as many no longer active as it was easier than checking each one.

In the news today is the story about Pascal Coler. He received the first FULL face transplant. He had spent much of his life horribly disfigured by Von Recklinghausen's disease. It is a rare genetic disorder suffered over 100 years ago by Elephant Man Joseph Merrick (played by John Hurt in the movie). I am watching this procedure with much fascination at the possibility for improving someone life. This case is a great example. Yes, there is the great risk with this procedure, but in this man's case and in his words

"My chance had finally come. Even with the risk of dying, there was no question of me hesitating."

The surgery took 16 hours and was done by French surgeon Laurent Lantieri and his team. First all the growths were removed before carefully removing the rest of Pascal's face, cutting over the left eyebrow, across and under the right one, and then down and around in a complete oval. Then they carefully connected tissues, nerves, arteries and veins before sending him back to the ward. For more of the story and pictures of Pascal before and after go here and here.

Dog attack victim Isabelle Dinoire was given the world's first partial face transplant in 2005.

Brigham and Women’s Hospital is the first in the United States to receive permission for the procedure (2008). Similar operations have been performed in France and China.

Caring for Family

Updated 3/2017-- all links removed as many no longer active as it was easier than checking each one.

Dr Sid Schwab's recent post and the comments are the reason for this post. There is a question of whether doctors/surgeons should take care of family/friends. There's the question of guilt if something goes wrong. The flip side of that is how much guilt should we feel if we don't and something goes wrong. I personally think it depends on the situation. I think often it is a privilege, as with any patient, to be able to do so or at least to be involved in their care. I have not always been able to (usually due to schedule or distance) to be there, but here are some examples of when I was able.

When my niece, K, was 4 yr she had to have eye surgery. My sister asked me to be with her in surgery. Not to do the surgery, as my field is plastic surgery, but to be with her, to hold her hand, etc. I don't think it did as much for my niece as it did for my sister. I recall my heart breaking as I helped hold my niece down (This was 18 years ago and preop Versed use wasn't as good as it is now in children.) as anesthesia was induced and the IV started. I did the "hard" thing and did not give it to someone else to do. My sister had "charged" me with the task. I stayed with my niece until my sister could be back with her.

I was there when my niece K was born. My sister J had not gone through Lamaze classes with anyone. I was lucky enough to be back in Arkansas during a break. The labor department wouldn't allow my mother to be with her as she had not attended the classes (though she had eight children of her own). My sister's Ob-Gyn was a classmate from medical school. He over-rode the nurses (who were just obeying hospital rules) and allowed me to be there. I think I helped her by being there. Though there came a time when I "lost" patience with her and remember telling her to "quit screaming and push".

My niece T had to have her tonsils out. I happened to know the anesthesia group at the hospital, but didn't have privileges there. I asked one of my friends (anesthesiologist) to take care of her. He became my "stand-in". He treated her as if she were his daughter.

More than ten years ago, my mother had a ruptured diverticuli. She needed an exploratory laproscopy with partial colon resection. She was horrified at the thought of maybe needing a colostomy. Her general surgeon, my friend, allowed me to be with her. I helped the nurses get her settled on the OR table, held her hand as the CRNA put her to sleep, opened supplies an needed, etc. I hadn't planned on scrubbing in, but when he asked if I would like to do so--I jumped at the opportunity. I held retractors, etc. Simply assisted. She did not need the colostomy.

When my sister C had her hysterectomy at a hospital where I have privileges, I went with her. I held her hand as anesthesia was induced. I then sat up near the head of the table, out of the way. Her Gyn didn't ask me to scrub in and I didn't ask. I had already "picked" her team, asking scrub nurses and circulating nurses to be with her.

When my mother-in-law had her renal artery aneurysm surgery, I did not go with her to the operating room. However, after she "bounced back" a week after discharge with a hot gall bladder, I did. My husband was in the waiting room. I held her hand as her CRNA gave anesthesia, helped with whatever needed to be done. My presence made both her and my husband less anxious.

My sister S, had a broken patella repair in Arizona. It was going to cost her more to have the wire removed after she healed than it would cost her to fly to Arkansas and have me remove it. So I did so.

If one of my nieces or nephews needed a laceration repaired, I think I would want to be the one to do it. They bring their teddy bears to me for a "plastics repair" so I hope they would call me for their own "plastics repair".

I have never allowed my family to make me their "family doctor". I don't want to be responsible for their diabetes (Type II), their hypertension, etc. They have respected that though I am often asked "can't you get brother J to do this or that for his diabetes?" I can't make any of them do "something for their health" anymore than they could get me to give up chocolate.

As a physician and a surgeon, I try to remember I am no more perfect than anyone else. I try not to "beat" myself up when I have a complication. Notice the try. Some times I do better than others. I do review each one and try to learn from it, figure out what I could or should have done differently. Sometimes there are no clear answers.

SurgeXperiences 118--Call for Submissions

Updated 3/2017-- photos and all links removed as many no longer active as it was easier than checking each one.

The next edition (118) will be hosted by the guys at OpNotes on March 30th. SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The deadline for submissions is March 28th. Please submit your posts here.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Five Feet High and Rising

Updated 3/2017-- video and all links removed as many no longer active as it was easier than checking each one.

Due to the recent rains, there has been some serious flooding around the country. Here in Arkansas, the Black River crested on Thursday at 29.7 ft, 15.7 ft above flood stage at Black Rock. The White River was expected to crest today at 27 ft, 12 ft above flood stage at Batesville; and at 32 ft, 16 ft above flood stage at Newport.

You may recall that Johnny Cash was from Arkansas. This song (Three Feet High and Rising) of his seems appropriate. Enjoy (hopefully on dry land).

There is an amazing gallery of photos here that includes the one below of all the cows seeking high ground.

Navaho Blues Quilt Top

I recently finished piecing this quilt top. The pattern is called Navaho Blues. I found it in "The New Quilting and Patchwork Dictionary" by Rhoda Goldberg. I really like that book and have spent many hours looking through it and using it for quilt inspiration.

The blocks are 2 in X 4 in. The size of the quilt can be varied easily by using that 1-to-2 ratio of the basic block size. My quilt top measures 54 in by 76 in. It calls for six different blue colors ranging from light to dark. I think it would work up well in any color scheme and may try a red or green in the future. I plan to machine quilt it over the next several weeks. When I am done with it, I will be giving it to a friend.

A close up view so the fabrics can be seen.

The Philoctetes Project

Updated 3/2017-- all links removed as many no longer active as it was easier than checking each one.

Yesterday I received my Phi Beta Kappa "The Key Reporter" spring 2008 issue in the mail. There was an article titled "The Difficult Patient, a Problem Old as History (or Older) by Abilgail Zuger. It was linked to the next article "About The Philoctetes Project" by Bryan Doerries.

If you happen to live near enough to Bard College (Annandale-on-Hudson, NY), you can attend for free this Saturday, March 22, 2008, at 2:00pm. There will be a dramatic reading at Bard College's Richard B. Fisher Center for the Performing Arts, featuring: Michael Stuhlbarg, Jesse Eisenberg, John Schmerling, and Adam Ludwig, followed by a panel discussion with: Norman Austin, Daniel Mendelsohn, Alice Quinn, and Jonathan Shay.

If like me, you live too far away, you may Click here to watch a recent performance of Philoctetes. It is well worth it!!!
Click here to participate in the ongoing discussion about The Philoctetes Project.

Check out Dr Sid Schwab's recent post: Time for Tears, Tears for Time

Spring is Here--Sun Protection Reminder

I first posted this last May, but it never hurts to be reminded.

Patients (& friends) often ask me which sunscreen they should use. Often this is more for skin aging protection than sunburn protection. The answer is the same. The best sunscreen is the one they will use. It has to "feel" good to them--not be too greasy, not have the wrong scent, be the right consistency (lotion vs cream). It will not matter if it is SPF 15 or 3o if it never gets used. The next thing I tell them is to use it daily, all year around, especially on the face and neck. If they are in the habit of applying sunscreen to their face daily (even on overcast days), it won't be forgotten.

For a more scientific answer, you need both UVA and UVB protection. It is the UVA rays that are most responsible for wrinkling and aging the skin. It is the UVB rays that are the most responsible for the sunburn. The best sunscreen is at least an SPF 15 and has a sunblock component also. The SPF rating reflects the product's ability to screen or block UVB rays only. SPF 15 blocks approximately 93 percent of all incoming UVB rays. SPF 30 blocks 97 percent; and SPF 50 blocks 99 percent. To protect against the UVA rays, the product needs to have avobenzone (Parsol 1789), ecamsule (Mexoryl), titanium dioxide, or micro-zinc oxide.

• Apply the sunscreen 20-30 minutes before going outside.
• Use enough. To ensure that you get the full SPF of a sunscreen, you need to apply 1 oz – about a shot glass full.
• Reapply after getting out of the water or toweling off. Even "water-proof" sunscreens are not usually "towel-proof".
• Reapply every two hours when outside at a beach, etc. for adequate protection.
• Use even on a cloudy day. Up to 40 percent of the sun's ultraviolet radiation reaches the earth on a completely cloudy day.
• Shield your eyes with UV-blocking sunglasses. Squinting caused wrinkles around the eyes. The UV rays can cause cataracts.
• Wear a wide-brim hat to help protect your head & neck.
• Don't forget to apply lip balm with SPF 15 or higher.

The Skin Cancer Foundation grants its Seal of Recommendation to products that meet the Foundation's criteria for effective UV sun protection products. If you use a product make especially for the face (ie MD Forte Total Protector SPF 30 or Clinique's Super City Block Oil Free Daily Face Protector SPF 25) it will be less likely to cause skin irritation or acne outbreak with daily use. So spend more money on the face and then if you need to save money, do so on the body sunscreen (ie NO-AD SPF 30 Sport Ultra Block Lotion, Coppertone Water Babies Sunscreen SPF 45).

Tips for Surgery Patients

Some tips I give to surgery patients
Before Surgery

• Stop smoking -- smoking reduces blood circulation to the skin and impairs the healing process.
• Do not take aspirin. Stop taking any medications that contain aspirin 10-14 days prior to surgery. Aspirin may cause bleeding both during and after surgery.
• Herbal supplements, Vitamin E, and weight loss products should be stopped 10-14 days prior to surgery.
• Get active. It's good for your health.

The day before surgery

• Do not eat or drink anything after midnight the night before surgery.
• You may take your medications with a small sip of water the morning of surgery, unless given other directions. See above regarding aspirin, herbal supplements, etc.
• Call if you develop any skin cut or burns that look infected. It may be best to change your surgery date.
• The night before surgery shower and shampoo. Do not use hair conditioners or hair sprays. Some of these products are flammable.

The morning of surgery

• You may brush your teeth, but do NOT swallow any of the water.
• Please, do NOT wear moisturizers, creams, lotions, or makeup. It makes it difficult to get the grounding pad (electrocautery) and the EKG pads to stick.
• Acrylic nails may stay on, but use light-colored or no nail polish. The pulse oxygen monitor has trouble "reading" through the darker colors, especially the reds.
• Please, leave you jewelry at home. You will be asked to remove any you wear, and we would hate to lose it, whether because it is a valuable or just a sentimental piece.
• Wear comfortable clothing the day of surgery. Imagine dressing yourself when "drunk" or "weak and unsteady".

After surgery

• Arrange for a family member or close friend to stay with you the first 24-48 hours.
• Keep your dressings as clean and dry as possible. Do not remove them unless instructed to do so.
• Take it easy and pamper yourself. Avoid any straining or activities that would elevate your blood pressure.
• Cold or ice packs may help to reduce swelling, bruising, and pain. Packaged frozen peas or crushed ice in a zip-lock bag work well without being messy. If the ice feels able, you may use less often.
• If you are not nauseated, start with liquids and bland foods first. If these are tolerated, then you may progress to a regular diet. If nauseated, try carbonated soda and dry crackers. If it persists, you may need an anti emetic (ie Phenergan).
• Alcohol should not be consumed until you have stopped taking the prescription pain medication. It is not good to mix the two. Also, alcohol will dilate blood vessels and could increase your bleeding.
• The day of surgery walking to the bathroom and back to the bed or recliner or couch is enough movement. Over the next few days, you can begin to increase your activity as instructed.
• You should not drive for 24-48 hours after general anesthesia. You should not drive while taking prescription pain medication. The medications may slow your response time and may lead to an accident. It is also considered driving while under the influence (DUI).

As you heal

• Don't attempt to shower (even if allowed) until you can stand without dizziness for 45-60 minutes. It isn't worth a fall in the bathroom. Take a "sink bath" instead. The dizziness may be from the anesthesia, the pain medicines, or not being re-hydrated. Wait another day or two.
• Some patients experience a brief period of "let-down" or post-surgery depression. Often this is due to a subconscious expectation of feeling and looking better "instantly". It takes time to heal. Give yourself "permission" to do so.
• Pain medicine and decreased activity may constipate you. If it has been more than 2 days since your last bowel movement, take something like plum (or prune) juice, Milk of Magnesia, Exlax or Ducalax.
• Panty liners make great dressings. They are packaged sterile and have a protective backing that will keep blood and other fluids from leaking through to ruin your clothing.
• Avoid activities that would result in pulling your incision "apart". For example, reaching backwards or stretching for that upper shelf after breast surgery.

Some tips patients have given me to pass on to other patients
After a tummy tuck

• Wear a pair of old panties while showering to "hold" the drains/collection bulbs rather than just letting them hang. You'll feel more secure.
• Consider borrowing a walker. It will remind you to "stay bent" when walking.

After a thigh lift

• Before surgery, buy a "soft" toilet seat to use after surgery. The "hard" seat is painful to sit on.
• If you can, get a "soft and elevated" toilet seat. The raised seat will make it easier to "sit" and to "get back up".
• "Tie" your ankles together (12-18 inches) to remind yourself not to "pull them apart". It is so easy to forget and this can lead to open areas in the incisions.

Shadowfax is Back and BALD!

  Updated 3/2017-- all links removed as many no longer active as it was easier than checking each one.

You may recall my post back in early February -- Hair for Charity. Fellow medical blogger, Shadowfax, over at Movin' Meat was going to shave his head for charity. You can read his initial posts--"I'm a Beautiful Man" and "I get letters" that highlight his reasons. Well, he did it!!!

You can see his photos here. He raised $16,060.00, though you can continue to donate! Good work, Shadowfax!

SurgeXperiences 117

 Updated 3/2017-- photos and all links removed as many no longer active as it was easier than checking each one.

Let's begin with a little fun. There's plenty of serious stuff for later.

Scott who writes the blog, Polite Dissent, Comics, Medicine, Politics & Fun, recently had a post on "Fourth-Dimensional Surgery". In his words, "There’s something charming about seeing “futuristic” 30th century medicine as imagined by writers in the 1960s."

Scott's piece reminded me of Buckaroo Banzai and his fight with the evil alien invaders from the 8th dimension. If only surgeons were truly as cool as Buckaroo Banzai! The man was an adventurer, a neurosurgeon, and a rock musician. Buckaroo Banzai's band of men were called the Hong Kong Cavaliers. If you have never seen the movie, you should check it out. Very campy, but fun.

Here is a video of the closing credits of The Adventures of Buckaroo Banzai Across the 8th Dimension (1984).

For more fun, check out this game featured by Sterile Eye -- a free online flash game called Amateur Surgeon.

Okay, moving on to more serious posts, and may I say to you all--some very good ones.

What happens when the popularity of new surgical procedures outpaces science? David Gorski discusses this issue over at Science-Based Medicine.

Speaking of new surgical procedures, check out this post on NOTES meets the robot by Chris over at OpNotes. Is it a procedure ahead of its time?

Dr Wes discusses the "remarkable amount of excitement about closing patent foramen ovales (PFO's) or larger atrial septal defects (ASDs) to cure intractable migraine headaches based on observational studies, and many, many companies have rushed to develop devices for this indication".

Aggravated DocSurg discusses the winning attributes of a surgeon in The "A's" Have It. "Back in the Dark Ages (i.e., when I was in training) it was said that the most important attributes a surgeon could have in order to be successful were: 1)Availability, 2) Affability, 3) Ability" [Buckaroo definitely had all three!!!] DocSurg has so much more to say!

Dr Bruce Campbell, an amazing writer, submitted this post -- Inside Out. In it he tells how he imagines the surgical procedure he is about to perform. I would also like to direct you to another of his more recent stories -- Listening to Leviticus (It was printed in JAMA here).

Dr. Alice, Cut on the Dotted Line, is an intern in a general surgery residency. I love the enthusiasm she has. It is so obvious in this post, Real Surgery -- "I realized what a wonderful day I was having".

Dr Schwab, another amazing writer, discusses being a surgical hospitalist (again) in a recent post, Different Cloth. As always, he is thought provoking.

Chris, OpNotes, presents a look at surgeons "biases and old habits" when we determine both the need for surgery and the best procedure for a given condition. " Believe us when we say it isn’t pretty."

Sterile Eye talks about Retirement. "Lately I’ve had the pleasure of working with two recently retired surgeons. It seems to me retirement can be a more drastic moment in mentor based professions like surgery." Very thoughtful post.

Not sure, then do what Bone MD does. He re-exams a patient when there is doubt about the diagnosis of septic arthritis. A good thing to do.

Ever had that Sense of Doom? The one that tells you things may go horrible wrong. ER Stories tells of a recent case involving just that -- "There is nothing worse than a patient who has that look of impending doom in their eyes. We have to learn to recognize it and act on it fast." Then he tells another story about a patient acting totally weird--"the moral is that not EVERY one is crazy".

T, Notes of an Anesthesioboist, in her post The Edge of the Precipice writes "It was the second repeat C-section of the day.........Then it started happening. That sinking feeling that something was just not quite right. Like when you're watching a film of someone climbing up a dangerous incline......"

In the same vein, Dr Val recalls her experience with the patients you don't forget. As her attending put it-- "Inexperienced residents like you are wasting hospital resources on drug seekers!" Her story is a reminder that even a "frequent flier" in the ER can have truly serious problems.

QuietusLeo, an anesthesiologist in Israel who writes a blog called The Sandman. He writes about the events involved in the soldier's care and the emotions that came with the outcome. "on call in the ICU. There was a lot of activity surrounding an injured soldier......... Despite this, I wouldn't hesitate doing it all over under the same circumstances. Because. Because another man's son might have been my son." While you are there, check out some of his other posts.

Back to Dr. Alice, who finds things Unsatisfactory "and asking for help, I gave up and called the pre-code alert." Dr. Alice, don't judge yourself so harshly. Someday you may be as good as Bongi.

Check out this series from Bongi, other things amanzi,regarding difficult codes (or resus) in his recent posts, Resus Fun and tube and cuban resus and hands tied behind my back. All very well written.

"There's a big difference between mostly dead and all dead. Now, mostly dead ... is slightly alive." --Miracle Max, The Princess Bride

 

Mitch Keamy, The Ether Way, discusses just that in his post, Donation after Cardiac Death: Is mostly dead slightly alive? He also gives you some trivia on the first use of the above quote by Miracle Max, pre-Princess Bride.

Buckeye in his post, Transplant Shadiness, discussed some of the same from a different point of view. Then join him as he muses about life's tough breaks being Not Acceptable. "It took me a while to gather myself for the post op family talk. It went as you would expect. Devastation. Grown men and women crying. A wife stoically trying to keep herself together. Nothing cuts like the unabashed wail of a mother grieving her son....."

Leaving that discussion behind, go with Dr Alice on a Donor Run, "A donor run is when a transplant surgeon travels to an outlying hospital to harvest organs. ....."

Random Ness has done a post on the history of medicine told with a twist of humor. "Well, my tale here is not very humorous, more like horrific. And that brings us to the PDA, which is a landmark in the history of anesthesia in the whole wide real world. PDA means Public Demonstration of Anesthesia and this happened ..."
 

Sterile Eye tells us the story of why a common surgical instrument is called a peang in his post, "--this beautiful surgical instrument has many names. In Scandinavia it’s simply called a “peang” (pronounced [piaŋ]). For a long time I’ve wondered why we call it that. Here’s the story "

Anatomy on the Beach is a medical student in the Caribbean. In a recent post, Functional Anatomy, he was helping with a Mock exam. "I ended up writing only two questions and not tagging anything. One of them was a complicated clinical scenario that forced them to think about the venous anastamoses important in portal hypertension."

Street Anatomy has put together a gallery of anatomical street art. "The artists who did these pieces have helped put a little bit of anatomy into the lives of everyday people." Here's an example. This is graffiti I wouldn't mind having on my office building!

The Midlife Midwife writes "In my scrapbook of memories, I have one simple memory that is still very vivid." It is more a post on the simple act of service to a fellow human being than on surgery, but sometimes that's what is needed of us.

T, in her post The Last Day, "the O.R. was not the right place for this lovely woman to spend her last moments, unconscious.......a bunch of stressed-out docs and nurses scrambling to try and help her survive. She belonged with her family, ..... encircled by love"

 

This need of human contact is reinforced in Dr Val's post, Social Networks Improve Postop Pain and Length of Stay. Support by family and friends sure make my job easier. I try to remember to thank them for taking care of "my patient" for me. They are truly important in outpatient surgery.

Belly Tales discusses the lack of the access to a simple procedure in many women's lives in A Walk to Beautiful. "The cure for fistulas is a simple surgical procedure, but with access to modern health care often hundreds of miles away, the cure might as well exist on another continent."
 

TBTAM was herself at patient recently. She had to have Moh's surgery and wrote about the experience in Mohs Nose Woes-Part I and Part II. She even posted pictures for us. Take care, TBTAM.

Lisa, over at The Cushing's Disease Journey, tells about her latest surgery and the difficulty with pain relief, nursing staff, etc. After all she went through, she ends her post "My head hurts, but in a good "healing" sort of way." Keep healing, Lisa!

Doctor David has a nice post about a teenager who had surgery -- How do you know a teenage is well? Check it out. It will make you smile (IWMYS).

Chris Oliver, another physician/patient, continues his story of his life post gastric banding with posts on his recent Skiing (it had been a few years) and Rugby experiences. Wishing you continued success, Chris!

Midwife with a Knife got a new gastroenterologist recently who discussed the possibility of surgery to treat her problem. "He might not be my ideal gastroenterologist, but it's a step up."
 

Check out GruntDoc's latest pic in his helmet series. "Needs no further explanation."

 

Get the story on these Smokin' Slippers from Dr Bruce Campbell, then read Smoke Scream by Dr Sid Schwab.

Doug Atkins gives insight to the patient experience relative to heart valve surgery (bicuspid aortic valve) on Adam's Heart Valve Surgery Blog. The blog has some good information for patients.

Charles, Trusted Advisor Assoc, has a post about two personality types of surgeons, how they treated the family/patient, and asks: "The question is: when it comes down to something like that—life and death—who do you trust? Do you go with the credentialed expert? Or the one who cares?
I suspect Rob would make the same decision again. I suspect my sister would make hers again as well. How about you? Who(m) would you trust?"

A news link, via Dr Kevin, regarding a surgical mishap--Granny victim of colostomy confusion. Wow! It boggles my mind to think how that mistake was made!

I hope you have enjoyed this edition of SurgeXperiences. I enjoyed bringing it to you. The next edition (118) will be hosted by the guys at OpNotes on March 30th. Please, submit your posts here. The submissions should be made by March 28th.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Hope you all have a good week. I'll leave you with some music by Buckaroo and the guys

JoAnna's Baby's Quilt

My niece is having a baby in May. This will be her first. I ran across this panel at Hobby Lobby. The fabrics are so very soft -- velvet (blue sky), chenell (white), flannels (blue strip, green plaid, yellow), and fake furs (the dogs). So very soft. So I bought a couple of the panels and quilted this one for her.

Here is a detail view. The quilt measures 34 in X 45 in. Did I mention how soft it is? Especially the puppies!

The back is a white flannel. I embroidered the quilt "name tag" on the back of the spotted puppy's collar region.

Chris Oliver Blogspot

Updated 3/2017--photos and all links removed as many no longer active.

The above is from Chris' blog. It represents the weight he has lost since his gastric banding. Chris is Dr Chris Oliver, an orthopedic surgeon in Edinburgh. His blog is about his life and the changes since the surgery. It is full of information for patients and physicians with links on the left side-bar to articles comparing the different weight loss surgeries and videos of the procedures.

The picture to the right is Chris doing the running leg of a triathlon. He writes in his post -- "At 118Kg the Edinburgh New Years Day Triathlon was my first Triathlon, I had not been this weight for 25 Years! The event consists of a 400-metre swim, 11-mile cycle ride and a 3.5-mile run. I finished slowly in just about 2:31:30 (last place). Splits including transition were 17:14 swim, 1:07:49 cycle, 1:06:26 run."

The Sterile Eye

 Updated 3/2017--photo and all links removed as many no longer active.

Sterile Eye is a Norwegian medical videographer. On his blog he shares his "experiences and thoughts on this rather unusual line of work". I find it a fascinating view and hope you will check him out. Here is a recent example in Inner Scents:

"Normal tissue hardly smell at all. .......... Opening the abdominal cavity does not emit any smells, unless there’s some infected parts, necrotic tissue, pierced bowels or gas present.

Cutting the body is not in itself a source of foul scents, but the way it’s cut can cause smell.........."

Polite Dissent

Updated 3/2017-- all links removed as many no longer active.

Today I want to highlight a blog that I find fun. It isn't just medicine or surgery. Scott over at Polite Dissent writes about medicine in comics, television shows, etc. How they get it right. How they get it wrong. Enjoyable.

In this quick Picture Post, he makes this observation "A hint for the colorist: don’t color IVs red automatically. Giving blood, especially in the field, is very rare. Most commonly a saline solution is used, so the tubing and IV solution should be clear."

OpNotes

 Updated 3/2017-- all links removed as many no longer active.

Today I'd like to feature OpNotes. It is a new blog featuring informal discussions about new procedures, products, and ideas in the operating room. It has been very interesting. I look forward to following their growth. OpNotes was "born" February 2008 by a group at Columbia University. The two contributors so far have been Jaime Landman (Urology), and Christopher Kelly. I hope you will go over and visit them.

Drugs in our Water Supply

 Updated 3/2017-- all links removed as many no longer active.

The news today is full of the headlines -- "Pharmaceuticals in Drinking Water".

As I mentioned in my post on "Unused Medicines", the question of what to tell patients to do with unused medicines has changed since I was in medical school. We were taught to tell patients to flush them. That is not a good idea. But what do we tell them? It seems that the new advise is not always always clear. The two best sites I found were the American Pharmacy Association and the White House Drug Policy.

The Federal Guidelines state:

• Take unused, unneeded, or expired prescription drugs out of their original containers and throw them in the trash.
• Mixing prescription drugs with an undesirable substance, such as used coffee grounds or kitty litter, and putting them in impermeable, non-descript containers,such as empty cans or sealable bags, will further ensure the drugs are not diverted.
• Flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so ( see list below).
• Take advantage of community pharmaceutical take-back programs that allow the public to bring unused drugs to a central location for proper disposal. Some communities have pharmaceutical take-back programs or community solid-waste programs that allow the public to bring unused drugs to a central location for proper disposal. Where these exist, they are a good way to dispose of unused pharmaceuticals.

The FDA advises that the following drugs be flushed down the toilet instead of thrown in the trash:
Actiq (fentanyl citrate)
Daytrana Transdermal Patch (methylphenidate)
Duragesic Transdermal System (fentanyl)
OxyContin Tablets (oxycodone)
Avinza Capsules (morphine sulfate)
Baraclude Tablets (entecavir)
Reyataz Capsules (atazanavir sulfate)
Tequin Tablets (gatifloxacin)
Zerit for Oral Solution (stavudine)
Meperidine HCl TabletsPercocet (Oxycodone and Acetaminophen)
Xyrem (Sodium Oxybate)Fentora (fentanyl buccal tablet)

Lisa and Cushing's Disease

Updated 3/2017-- photos and all links removed as many no longer active.

Taking a cue from the media, I'm going to preview a few blogs for the next SurgeXperience (117 to be posted here on March 16th). If you have a surgery related post, you are encouraged to submit it here! Thank you for doing so.

The first one I wish to bring to your attention is Lisa and her blog, The Cushing's Disease Journey. I won't link to the specific post she submitted, but please check out her blog. She started her blog back in October 2006 and has shared her journey and information about Cushing's Disease along the way. The blog is well written and very worthy of your time to check it out. It is also interesting to see things from the patient's viewpoint. She even shares her scans with us.

SurgeXperiences 117 -- Call for Submissions

Updated 3/2017-- all links removed as many no longer active.

I have the honor of hosting the 17th edition of SurgeXperiences on March 16th.  SurgeXperiences is a blog carnival about surgical blogs.  It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.  Though they should be about humans and surgery, I think, rather than this article that goes with the  photo.  The deadline for submissions is March 14.  Please submit your posts here.  I look forward to hearing from you all.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

International Women's Day

 Updated 3/2017-- photos and all links removed as many no longer active.

Today is International Women's Day (IWD). It is the global day meant to connect all women around the world and inspire us to achieve our full potential. This is my wish for all women on this day and every day whatever field or dream they wish to pursue.

Reuters News has a very nice slide show on "Being a Woman". It only begins to touch the surface, but it is worth checking out.

Margaret Allen, MD was born 1948. "She entered the University of California, San Diego Medical School knowing she liked learning how things work, liked to fix problems and liked to work with her hands. A career in cardiothoracic surgery seemed a natural for her, an assumption later born out in 1985 when, working at Stanford University as a resident with famed cardiac pioneer Dr. Norman Shumway, she became the first female surgeon in the United States to transplant a heart."

MORE INSPIRATION
Women Physicians 1850s-1970s; Drexel University College of Medicine Archives & Special Collections
Women in Medicine; University of Virginia Health System
Women in Surgery: Past, Present, and Future; Dixie Mills MD (PDF file)

Another Grandbaby Quilt

I recently finished this grandbaby quilt which started from left-over blocks from the Snail's Tail Quilt. I used four of the blocks as a medallion in the center. I found some lovely "cowboy" fabric to frame the center, and the "dot" fabric for the border. I had the two reds and the light brown (from the snail's tails blocks). The quilt is 38 in X 48 in. I plan to give it to an "old friend" who I have known for more than 30 years.

A detail view. The quilt is machine pieced and quilted.
Another detail view. The quilting thread is a brown variegated thread.

Dr Anonymous Show on Talkshoe

 Updated 3/2017-- all links removed as many no longer active.

I have enjoyed several of the Dr Anonymous BlogTalkRadio Shows.  Tonight his guest is  Bertalan Mesko from the blog called Science Roll.  The show is live, 9 pm EST, and this guest lives on a different continent from Dr A, so he will be broadcasting live on Talkshoe.
He gives detailed instructions here for using Talkshoe. 
For first time Talkshoe listeners:

• Although it is not required to listen to the show, I encourage you to register on the Talkshoe site prior to the show. I think it will make the process easier. To get to my show site, click here.
• Talkshoe has software called "ShoePhone" in which just by plugging in a headset, you can talk on the show without dialing a phone number. After registering your ID, I encourage you to click here and download and install the shoephone software.
• When the show goes live, make sure your headset is already connected and then log into the site. Then, click on the button below to activate the shoephone software.
• This will open a window called "Talkshoe Pro." Look for the shoephone button below and click on it.
• You will then see the Talkshoe interactive software window as below. There is a chat room in there. And, you will be able to see who else has a microphone. Who knows, I may unmute you to say hello!
• Now, of course, you don't have to download the software to listen to the show live or listen to the show later. And, if you want to dial in with your cell phone to talk on the show, you can do that as well. Click on my link above to get the phone number and ID number of the show. But, why would you want to do that when there is a free option? See you for the show!

I guess the answer to that question, for me anyway, is that some of us don't own headsets with microphones.  I would still need to call in, but that's okay. 

Silicone Implants and Health Issues

 Updated 3/2017-- all links removed as many no longer active.

There are many questions and concerns about silicone gel implants and the effects on the health of the woman or her child. The Supplement to the Journal of Plastic and Reconstructive Surgery covers several of these. I will try to hit the high points and conclusions. If you want more, then these articles have very nice reference lists themselves.

Silicone Implants and Connective Tissue Disease

Dr Hölmich and colleagues did a comprehensive search of PubMed, EMBASE, and The Cochrane Library. They added manual searches using the related link facility to extend the number of references identified. They identified additional references by cross-checking the reference lists of the identified publications. Here are their conclusions:

• There appears to be little scientific basis for any association between implant rupture and well-defined connective tissue disease or undefined or atypical connective tissue diseases.
• The concept of silicone-related disease was developed by rheumatologists based on highly selected groups of symptomatic breast implant patients seen in their practices.
• It is likely that nonspecific complications or symptoms related perhaps to capsular contracture or implant rupture may be misinterpreted as representing a systemic disease.

Anecdotal reports and case series have suggested that silicone implants may cause various diseases, in particular, connective tissue diseases, or a new silicone adjuvant syndrome. However, large-scale epidemiologic studies have consistently failed to demonstrate increased risks of these diseases among women with breast implants.

Silicone Implants and Breast Cancer

Soon after breast implants were commercially introduced questions about potential carcinogenicity were raised. Case reports of breast cancer following augmentation mammaplasty appeared. Two early surveys intended to address the question somewhat implausibly reported zero breast cancers among 16,000 women and one breast cancer among 10,941, respectively. In addition to the question of breast cancer incidence, the possibility of delayed breast cancer detection in the augmented breast and the risk of poorer survival have raised concern.

However, over the past 20 years, a robust body of literature examining breast cancer-related risks among breast implant patients has been published. This was reviewed by Dr Deapen. Here are the conclusions:

Risk of Breast Cancer

• The majority of studies report somewhat lower breast cancer incidence and mortality among implant patients. A comprehensive literature search and meta-analysis published in 2001 summarized results from 10 studies available at that time and estimated the relative risk for breast cancer as 0.72 (95 percent confidence interval, 0.61 to 0.85).

Delayed Detection of Breast Cancer

• There are clear reasons for concern that implant patients may experience delayed detection of breast cancer and poorer prognosis. Nevertheless, using stage at diagnosis and tumor size as indicators of detection delay, no consistent evidence of delay or decreased survival has been found.
• It is well-established that the silicone devices are radiopaque and obscure some portions of breast tissue from mammographic visualization, which may increase the risk of late detection. [One of the reasons for the FDA recommendation that these patients have periodic MRI's.]

Breast Cancer Length of Survival and Recurrence

• The risk of a local and distant recurrence of breast cancer was 50 percent of expected, a non-significant difference, and the risk of secondary breast cancer was no different from expected.

Breast Cancer and Mortality

• No difference in the breast cancer mortality experience has been found.

Silicone Implants and Breast Feeding

Despite the overwhelming advantages of breast-feeding, there is a persistent concern that maternal exposure to chemical contaminants may result in contamination of breast milk and have an effect on the child's growth and development. A parallel concern regarding lactation in women with silicone implants over the past years has led to confusion and anxiety relating to the potential risks to the child. Dr Semple reviewed the facts and issues as he knows them, including biomaterials, lactation toxicology, and a previous study where no difference was found in silicon (a proxy measurement of silicone) in women breast-feeding with silicone implants and those without. Here are his conclusions:

• A recent study revealed that there was no significant difference in the levels of silicone in breast milk and blood between two groups of women. One group of women was breast-feeding with silicone implants, whereas the group breast-feeding without silicone implants acted as a control group.
• Mothers with silicone implants may decide not to breast-feed because of the suspected risk of breast milk contamination. The alternative source of nutrition for these infants is a variety of commercially available formulas.
• It is well known that there are sources of silicone in the everyday diet, including its use as an antifoaming agent in fruit juices and other types of food. Infants have been given silicone drops for colic for many years, with no identifiable problems [Mylicon drops (Merck Consumer Pharmaceutical, Ft. Washington, Pa.), used in the United States, have 67 mg of polydimethylsiloxane per milliliter and Miniform, as used in Europe, has 94 mg of polydimethylsiloxane per milliliter].

Adverse Health Outcomes in Offspring of Mothers with Silicone Implants

Dr. Kjøller and colleagues attempted to assess the question of "whether maternal cosmetic breast implants are associated with adverse health outcomes among offspring". They examined published findings of epidemiologic studies (all of Scandinavian origin) that addressed this hypothesis. Here are their conclusions:

• Rates of esophageal and rheumatic disorders, congenital malformations, and perinatal mortality and hospitalization were comparable between children born to mothers with breast implants and children born to mothers who had undergone other cosmetic surgery.
• Based on this review, the epidemiologic evidence to date does not support an increased risk to offspring of women with breast implants for health problems such as esophageal and rheumatic disorders, congenital malformations, or perinatal mortality.

REFERENCES
Silicone Breast Implants: Outcomes and Safety; Supplement to Plastic and Reconstructive Surgery, Vol 120, No 7, Suppl 1, December 2007

• Breast Implant Rupture and Connective Tissue Disease: A Review of the Literature; Lisbet Rosenkrantz Hölmich, M.D.; Loren Lipworth, Sc.D.; Joseph K. McLaughlin, Ph.D.; Søren Friis, M.D
• Breast Implants and Breast Cancer: A Review of Incidence, Detection, Mortality, and Survival; Dennis Deapen, Dr.P.H.
• The Relationship of Silicone Breast Implants and Cancer at Other Sites; Louise A. Brinton, Ph.D.
• Breast-Feeding and Silicone Implants; John L. Semple, M.D., M.Sc.
• Adverse Health Outcomes in Offspring of Mothers with Cosmetic Breast Implants: A Review; Kim Kjøller, M.D.; Søren Friis, M.D.; Loren Lipworth, Sc.D.; Joseph K. McLaughlin, Ph.D.; Jørgen H. Olsen, M.D., Dm.Sc.

FDA Breast Implant Home Page

Silicone vs Saline Breast Implants

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

With the reintroduction of silicone implants into more general use and not simply in controlled studies, comparisons between silicone and saline are inevitable. Any comparison seems to be potentially biased, but I will try to give a fair one. To try to keep it simpler, I will stick to a comparison in augmentation use not reconstructive.

In general, normal saline implants are not thought of as first or second generation implants. Silicone gel implants are. Depending on who you read, silicone gel implants are either in their third or fifth generation. I'll give you the information from the first reference below (Supplement, page 45S):

Implant	Description
1st generation, 1962-1970	Thick, two-piece shell Smooth surface with Dacron fixation patches Anatomically shaped (teardrop) Viscous silicone gel
2nd generation, 1970-1982	Thin, slightly permeable shell Smooth surface, no Dacron patches Round shape Less viscous silicone gel
3rd generation, 1982-1992	Thick, strong, low-bleed shell Smooth and textured surface Round shape More viscous silicone gel
4th generation, 1993-present	Thick, strong, low-bleed shell Smooth and textured surfaces Round shape More viscous (cohesive) silicone gel Refined manufacturing processes
5th generation, 1993-present	Thick, strong, low-bleed shell Smooth and textured surfaces Round and diverse anatomical shapes Enhanced cohesive & form-stable silicone gel

So when comparing implants, saline to silicone or 1st generation to 4th generation silicone, there may be a distinct difference in years of follow-up. There is no long-term data yet available for the 4th and 5th generation silicone gel implants. The data from these latest generation of silicone implants are approximately 3 to 4 years old. The data collection period on saline implants (during the moratorium on silicone gel implants) spanned more than 15 years in the United States, and the information gathered has shown that saline implants are safe and effective.

There is still a lot of data on silicone implants, but not any 10 year follow-up on the new cohesive gel implants. So we are giving patients the information we have now, not what time may prove out. The following table compares complication rates between the two types of implants (information from 3rd reference mainly).

	Saline	Silicone
Rupture rate 1-2 yrs 3 yr 5 yr 9-10 yr	1-4% 3-5% 16% 7%	8% 0.5% 1% 8-10%
Contracture rates 1-3 yr 7 yr 10 yr	4-9% 11-16% 16.6%	8.1% 5.6% No comparison, 38.5-90% with earlier generation
Patient satisfaction	97% at 6 yrs	95% at 5 yrs, 87% at 7 yrs
Implant removal (1-4 years)	8% at 2 years 12% at 4 years	5.1 % at 3 years 7.5% at 4 years
Detection of deflation/rupture	Physician/patient able to detect	MRI at 3 yrs then every 2 yrs recommended by the FDA
Deflation rate	0.34/1000 implants
Implant cost range	1X	2X
Incision size	3-4 cm	6-8 cm
Integrity at 10 yrs	96.9-98%	not collected yet, projected to be 83-85%
Implant removal	Simple	Complicated

Consideration of incision size between the two types of implants is significant. Saline implants can be placed unfilled and so a small 3- to 4-cm incision can be used. Silicone implants must be placed through an incision almost twice that length, depending on the size of the implant used. The incision must be large enough that the silicone implant can be placed with ease, so that the gel is not fractured on placement. Brown et al found this to be at least 5 cm.

Cost is also a factor. The cost of saline implants is approximately 50 percent less than that for silicone implants. Satisfaction rates are high for both silicone and saline.

Hard to know what to make of the implant removal rates. Often the reasons for removal are to change size rather than to simply remove and leave out. That data is not often broken down further and it would be helpful if it were.

For me it is tough to justify going back to silicone gel implants in light of the satisfaction of the patient with saline, the difference in cost (both initial and long term as the MRI recommended by the FDA may not be covered by the patient's insurance), the size of the incision, the lack of clear advantage of silicone over saline.

Silicone implants do simulate the feel of breast tissue much better than saline implants ever will. They are therefore perceived as more natural to some patients. There may also be less palpable rippling and less potential for visible rippling with silicone implants. However, women with minimal subcutaneous tissue and/or poor skin turgor are difficult (if not impossible) to hide all rippling. The subpectoral placement can help this with either implant.

The Food and Drug Administration recommends a magnetic resonance imaging scan at 3 years after surgery using silicone gel implants, and then every 2 years thereafter. MRI is an excellent imaging modality in localizing free silicone and evaluating an implant for rupture. It has a sensitivity and specificity of greater than 90%. I don't order one if it won't change my plan of care. If the patient and I have already decided that (for whatever reason--age of implant, etc) that she needs to go to surgery, then why add the cost? The FDA's recommendations are to pick up "silent" ruptures.

Regardless of which type of implant is used for augmentation mammoplasty there are risks that are inherent to the surgery and are non-implant related. These include bleeding, infection, malposition of the implant, changes in nipple and breast sensation, and scar formation.

Breast implants interfere with mammography detection of breast cancer and require additional views and skilled technologists to compensate. So make sure you have your mammogram done at a facility that does a lot (more than a few a week) of women with implants.

With either implant, there WILL be future surgery. I posted about this with saline implants here.

REFERENCES
Silicone Breast Implants: Outcomes and Safety; Supplement to Plastic and Reconstructive Surgery, Vol 120, No 7, Suppl 1, December 2007
The FDA approves saline-filled breast implants: What does this mean for our patients?; Plast. Reconstr. Surg. 106: 903, 2000; Rohrich, R. J.
Breast Augmentation Today: Saline versus Silicone--What Are the Facts?; Plastic & Reconstructive Surgery. 121(2):669-672, February 2008; Rohrich, Rod J. M.D.; Reece, Edward M. M.D., M.S.
Cohesive Silicone Gel Breast Implants in Aesthetic and Reconstructive Breast Surgery; Plast. Reconstr. Surg, 116, 768, soo5; Brown MH, Shenker R, and Silver SA
Rupture and aging of silicone gel breast implants. Plast. Reconstr.
Surg. 91: 828; discussion 835, 1993; de Camara, D. L., Sheridan, J. M., and Kammer, B. A.
Mentor Corporation. Saline-Filled Breast Implant Surgery: Making
an Informed Decision. Product Insert; Mentor Corporation,
Santa Barbara, California: 2005.
FDA Breast Implant Home Page

Breast Implants -- Some History

One of AOL News stories this morning is "Making a Comeback: 20 Trends to Watch in 2008". The number one listed is Silicone Implants. So I am going to try to look at "just the facts". I will try to cover some of the history of implants and the controversy.

Here is a time line of breast implants in the United States:

1962 -- Silicone gel-filled implants first available as a result of Tom Cronin, MD and Frank Gerow, MD's work with Dow Corning

1976 -- US Food & Drug Administration (FDA) given Congressional authority to regulate medical devices. Silicone gel-filled breast implants were "grandfathered in" pending further review.

1988 -- FDA classified breast implants as Class III medical devices. This set in motion a process requiring manufacturers to demonstrate safety and effectiveness in a pre-market approval application.

1962-1988 -- A number of different implant designs and modifications were developed. These included double-lumen, reverse double-lumen, triple-lumen, smooth surface, textured surface, polyurethane-covered, thick shell, thin shell, barrier shell, and implants of varying gel cohesivity. Also, during this time other manufactures joined Dow Corning in the marketplace. Some of these companies included Bioplasty, McGhan (became Inamed in 2001, then Allergan Corp in 2006), Mentor (absorbed American Heyer-Schulte in April 1984), and Surgitek .

1991 -- FDA held an advisory panel meeting on silicone gel-filled breast implants. In September, sent letter to manufacturers accepting Pre-market Approval Applications (PMAAs) for review with a listing of major and minor deficiencies.

Sept 1991 -- Bristol-Meyers Squibb Company announced its decision to withdraw from the breast implant market and closed the plastic surgery unit of its Surgitek subsidiary.

January 1992 -- FDA called for a 45 day moratorium on the sale and use of silicone gel-filled breast implants. Later moratorium extended until recently. Saline implant use allowed.

February 1992 -- FDA reconvened General and Plastic Surgery Devices Panel to review "new material". The Panel recommended limited availability of implants under carefully controlled clinical protocols for augmentation mammoplasty. The Panel recommended broader access for reconstruction patients.

March 1992 -- Bioplasty announced withdrawal of its PMAAs for its single and double-lumen gel-filled breast implants.

April 1992 -- Dow Corning Corporation announced it's withdraw for PMAAs for silicone gel-filled breast implants.

April 1992 -- FDA announced 1) extension of the PMAAs for silicone gel-filled breast implants for reconstruction under the public health extension while studies are conducted and 2) denial of PMAAs for silicone gel-filled breast implants for cosmetic purposes while studies are conducted (limited availability under investigational device study).

1992 -- Mentor began its Core and Adjunct Studies
1998 -- McGhan received approval to initiate its Core and Adjunct Studies.
2005 -- FDA approved Mentor's application to market its Memory Gel Implants.
In 2006 -- the FDA approved silicone implants for general clinical use in breast augmentation.
November 2007 -- FDA approved Allergan's application to market its Inamed silicone-filled breast implants.
REFERENCES
Silicone Breast Implants: Outcomes and Safety; Supplement to Plastic and Reconstructive Surgery, Vol 120, No 7, Suppl 1, December 2007
ASPRS Breast Implant Resource Guide; May 1992

Little Rock Marathon

I volunteered as part of the medical staff at the Little Rock Marathon today. I worked the 1st relay stop and later the 3rd relay stop. We only had mostly minor stuff -- some blisters, some muscle cramps, some mild heat/dehydration issues. At the 3rd relay stop, we did have some more major muscle cramps and dehydration issues. There was a death today. Adam Nichols, 27 yo, from Wisconsin collapsed at the finish line around 11 am. It was his 6th marathon. I would like to give my condolences to his family and friends.

Above picture taken at the 1st relay station.

Below, a T-shirt that caught my eye.

Another T-shirt that caught my eye.

Both made me smile.
The rest of these were taken at the 3rd relay station.

SurgeXperiences 116 is up!

 Updated 3/2017--photo and all links removed as many are no longer active.

The 16th edition of SurgeXperiences, hosted by South African surgeon, Bongi, over at his blog Other Things Amanzi is up! It is worth reading. I hope you will.

I will be hosting the next edition. The deadline for submissions will be March 14th. Start writing and submitting here!

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here