I finished earlier this month and mailed it to a friend whom I wish I could wrap my arms around. This seems so inadequate but is the best I can do at this time.
I am a plastic surgeon in Little Rock, AR. I used to "suture for a living", I continue "to live to sew". These days most of my sewing is piecing quilts. I love the patterns and interplay of the fabric color. I would like to explore writing about medical/surgical topics as well as sewing/quilting topics. I will do my best to make sure both are represented accurately as I share with both colleagues and the general public.
Recently I had a patient call to tell me to report that her right breast implant had deflated. She is a patient from the early years of my practice. This is her second deflation, but this one is complicated by pregnancy. She has listened to my “lectures” over the years and was not panicked. She wanted to check in with me.
I reminded her
I told her I would report the deflation to the implant company and get a file number for her case. When she has delivered a healthy baby and finished breast feeding, then she should call me back. At that time we will arrange a visit and decide what she wants to do (remove or replace; same size or smaller/larger; etc).
We didn’t discuss costs at this point in time. We will later. She unfortunately was augmented prior to the “extended warranty” offers that both Mentor and McGhan (INAMED) have now. The programs didn’t exist prior to October 2, 2000. The company will offer free implants for replacement.
Locally, the surgery center I use charges $840, anesthesia’s charge is $525, and my fee is $***(depends on time passed since surgery and whether I was the initial surgeon). I began paying for the “extended warranty” for each patient out of my fee back in 2002 when I realized too many of them were failing to spend the extra $100.
I truly appreciate the patient who remembers the preoperative discussion and who read the information brochure. I try very hard to make sure the woman knows that the saline implant is not permanent. Approximately 1% deflate within 1 year, 3% within 3 years, and 10% within 5 years. Because of the warranty set at 10 years, I caution all of them that the mean deflation is 10-12 years (or half at that point). I tell them that it is rare to have a deflation at 1 year, but it can happen. And yes, the implant may last for 20 years, but don’t count on it. I tell them to begin saving money, if they get to 8-9 years without a deflation because they will likely end up out of the extended warranty period.
And all this is said on top of reminding them that this is surgery, the risks of surgery are infection, bleeding, anesthesia/drug reactions, scar, loss of/or decrease nipple sensation. The risks due to the implant include capsular contracture, asymmetry, visible wrinkling of the implant, deflation, repeat surgery to correct any of the before mentioned problems. You will need to be more careful with your mammograms. Four views will need to be done rather than just two. Make sure you go to a facility that is comfortable with implants and do mammograms often on women who have implants.
Other Posts of Interest:
It Happened Again (June 5, 2007)
Breast Implants – Some History (March 3, 2008)
Silicone vs Saline Breasts Implants (March 4, 2008)
Silicone Implants and Health Issues (March 5, 2008)
This article is a CME (continuing medical education) article. As such it is a review of complications of rhinoplasty. It is a good review and worth reading.
Complications of rhinoplasty can be classified into hemorrhagic, infectious, traumatic, functional, or aesthetic problems. Here is a summary of the article.
Postoperative bleeding is one of the most common
complications following nasal surgery.
Epistaxis -- The most common causes of mild epistaxis are bleeding from the incision sites and traumatized
For mild to moderate epistaxis being with
If bleeding persists
Continued bleeding may require a formal nasal pack, either in the form of gauze or a commercially available nasal tampon.
Bleeding that persists despite anterior packing may signify
a posterior bleed from a branch of the sphenopalatine
artery. If so, a posterior pack may be required.
Serious bleeding occurs in less than 1 percent of patients, but warrants operative exploration when conservative measures fail.
Septal Hematoma -- is a potentially serious complication of rhinoplasty. These patients may present with symptoms of nasal obstruction, pain, rhinorrhea, or fever. The typical finding on physical examination is an ecchymotic nasal septal mass.
Untreated septal hematoma may lead to cartilage necrosis with subsequent loss of dorsal support and a saddle-nose deformity.
Postoperative infections following rhinoplasty can range in severity from mild cellulitis of the soft tissue envelope to life-threatening systemic illness resulting from cavernous sinus thrombosis or toxic shock syndrome.
Local wound infections (such as cellulitis) -- treat with systemic antibiotics and close observation.
Abscesses require prompt surgical drainage in addition to antibiotic therapy. Common sites of abscess formation following
rhinoplasty include the nasal dorsum, nasal tip, and septum.
Cavernous sinus thrombosis, meningitis, or a brain abscess may result without adequate treatment of a septal abscess.
Toxic shock syndrome is an acute, multisystem disease. It has been described after nasal surgery with the use of both nasal packing and intranasal splints. Symptoms occur early and can include nausea or vomiting, rash, fever, tachycardia, and hypotension. Treatment requires the immediate removal of the offending object (packing or splint), intensive care unit admission, intravenous antibiotics, and supportive care.
L-Strut Fractures --
When L-strut fractures occur, they should be repaired immediately to prevent significant deformity. If it isn’t, the cartilaginous septal segment will tend to rock posteriorly, resulting in a loss of dorsal support and a saddle-nose deformity.
Depending on the location of the fracture, it may be stabilized with either spread grafts or a combination of spreader grafts and
Intracranial Injury and Cerebrospinal Fluid Leak
Intracranial injury and cerebrospinal fluid leaks are a major complication after rhinoplasty. They can happen with the cribiform plate it violated by surgical instruments or from excessive bony septum manipulation. Either can result in a cerebrospinal fluid leak and potential intracranial injury or infection.
Symptoms of a cerebrospinal fluid leak include clear rhinorrhea and positional headache. The diagnosis may be confirmed by testing the fluid for the presence of 2-transferrin, a protein highly specific for cerebrospinal fluid. A
Treatment requires hospitalization, bed rest, and prompt otolaryngologic and neurosurgical evaluations.
Epiphora -- after rhinoplasty is most commonly occurs due to compression of the lacrimal system by the soft-tissue edema. It normally resolves after 1 to 2 weeks.
Septal Perforation -- are most often caused by opposing tears in the elevated septal mucoperichondrial flaps with no intervening septal cartilage. They may also result from decreased blood flow to those same flaps from an unrecognized septal hematoma or tissue necrosis from septal stitches.
Symptoms of a nasal septal perforation include crusting, bleeding,
whistling, and nasal airway obstruction due to disruption
of the normal laminar airflow through the nasal passages.
Intranasal Adhesions -- (synechiae ) result from cicatrical healing of opposed, abraded mucosal surfaces.
Patients may present with nasal obstruction. Intranasal examination will reveal a “bridge” of mucosa from the septum to the inferior turbinate, middle turbinate, or lateral nasal wall.
Treatment requires division and placement of a barrier between the incised surfaces, such as a Silastic splint, until the surfaces undergo complete re-epithelialization.
Postoperative Septal Deviation -- whether new or uncorrected, following septorhinoplasty is a source of frustration for both the patient and the surgeon. Any significant septal deviation that persists and causes cosmetic or functional impairment may require revision surgery.
Rhinitis – Atrophic rhinitis is due to atrophy of the nasal mucosa usually due to overresection of intranasal structures such as the middle or inferior turbinate.
Patients often present with subsequent symptoms of dryness, crusting, and nasal obstruction. These patients will get relief with nasal saline.
Patients may also report a spontaneous clear watery nasal discharge. This phenomenon is most likely due to a variant of vasomotor rhinitis caused by abnormal parasympathetic tone to
the intranasal mucosa. These patients are often effectively treated with topical anticholinergic preparations, such as 0.03% ipratropium bromide which act locally to decrease the watery rhinorrhea. The recommended dosing regimen is two sprays in each nostril two to three times a day as needed.
Continued symptoms of watery nasal discharge despite appropriate topical therapy should raise the concern for an occult cerebrospinal fluid leak.
Tip and Dorsal Deformities
Postoperative deformities of the osseocartilaginous framework may be caused by overresection or underresection of the osseocartilaginous framework, incorrectly performed osteotomies, incorrect shaping of grafts and their edges, and migration of grafts due to insufficient or inaccurate fixation.
Persistent tip or dorsal deformities are generally not treated until at least 1 year after the previous rhinoplasty.
Supratip (“Pollybeak”) Deformity -- is a postoperative complication of rhinoplasty in which the nasal supratip assumes a convex shape in relation to the nasal dorsum. The deformity results either from inadequate resection of the lower dorsal septum and upper lateral cartilages or, paradoxically, from overresection of these supratip structures with subsequent scar tissue formation in the resulting dead space.
Patients who develop supratip fullness should be instructed to apply compressive tape onto the supratip area nightly. This is generally effective in treating transient postoperative swelling. Taping should be discontinued when a permanent depression is obtained.
Steroid injections can improve excessive swelling and reduce scar tissue in the supratip area. The injections can be used in patients who continue to supratip fullness despite compressive taping. Triamcinolone acetate, 1 to 2 mg, is injected below the
dermis in the supratip area. The injections may be repeated at 2-month intervals until an aesthetically pleasing supratip contour is obtained.
Side effects of the steroid injections should be remembered. The most frequent is dermal atrophy, which may lead to a contraction
deformity of the skin. Other side effects include telangiectasias, depressions, color changes, and eventual visibility of the underlying cartilages or contour imperfections, which may be enhanced by the resulting decrease of skin thickness.
Corrective surgical procedures should not be performed until
at least 1 year after the initial procedure.
The basic principles include judicious removal of the offending cartilage or scar tissue, adjustment of the osseocartilaginous framework so that the differential between the midvault and the tip is adequate, elimination of dead space by establishing direct contact between the underlying framework and the skin, and application of a dressing with selective compression over the supratip area.
Postrhinoplasty Nasal Cysts -- are a rare complication
of rhinoplasty. The most common site of occurrence for both types of cysts is the nasal dorsum. Both may require complete excision.
Contact Dermatitis and Skin Necrosis --
Contact dermatitis may result from irritation of the skin by the topical adhesives, tape, or dorsal splint. It usually resolves without any permanent sequelae.
Treatment of contact dermatitis
Superficial skin necrosis or epidermolysis can occur secondary to excessive compression of the skin by the taping and dressing. More problematic is partial-thickness or full-thickness skin necrosis that can occurs when the blood supply of the soft-tissue envelope is severely embarrassed.
Treatment of minor skin necrosis should initially be conservative.
Telangiectasias -- are small superficial vessels of the skin visible to the human eye and usually measure 0.1 to 1.0 mm in diameter. Argon and pulsed dye lasers have proven to
be an effective means of treatment.
Prevention and Management of Rhinoplasty Complications; Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 60e-67e; Cochran, C Spencer M.D.; Landecker, Alan M.D.
Welcome to Grand Rounds Vol 5, no 23! We've got a wonderful pot luck menu of great posts from around the medical blogosphere, so sit right down and dig in!
The fourth edition of Change of Shift (Vol 3, No 16) for 2009 is hosted by Amanda (This Crazy Miracle Called Life)! It’s the “Valentine” edition. I hope you will check it out (photo credit). You can find the schedule and the COS archives at Emergiblog.
The best classification of natural toxins involves dividing the groups of toxin-containing organisms into poisonous and venomous.
° Poisonous organisms are those that are assimilated into the host either by ingestion or through the skin. Included are bacteria, fungi, plants, and some animals.
° Venomous organisms are those that have evolved specific toxin delivery systems, which usually include a venom gland and a sting, fang, spine or pore for transporting venom to the host. Venomous animals are found in every class of animals and are distributed throughout the earth's ecosystems. The first venomous member of the class Aves (birds) - the genus Pitohui, from New Guinea - was described in 1992.
Twittering in the OR – interesting, but is this the best use of a chief resident. Shouldn’t he be learning and doing something else?
As CNN reported yesterday, physicians used Twitter to give a blow-by-blow account of removing a cancerous tumor from a man's kidney at Henry Ford Hospital in Detroit. (CNN notes that you can read the "Tweetstream" and link to the YouTube video here).
The surgeon's musings during the operation were dutifully recorded in real time on Twitter by the chief resident.
Members of Quilters of South Carolina have created one-of-a-kind bras for Breast Cancer Awareness. The exhibit consists of fifty original works of art which are unique, entertaining, humorous, and beautiful to make the public aware of breast cancer, to memorialize those lost to the disease, and to honor survivors.
This exhibit will tour SC until Oct '09 at which time individual Artfull Bras will be auctioned and the proceeds donated to the Best Chance Network, a program to provide care and treatment of uninsured women across the state who are diagnosed with breast and ovarian cancer
And I love my dog and have even made him homemade dog biscuits. I didn’t know there was an International Dog Biscuit Day until Johann (photo credit) told me so. It was yesterday. Check out all the sources (many more than the ones below) listed in this post.
Here are some super fun links to help you enjoy this great day:
You can check out the archives of his Blog Talk Radio show. Here is the upcoming schedule:
3/12: 4th year medical student Mudphudder to talk about Match Day 2009
3/19: Respiratory therapy student Trauma Junkie to talk about the blog carnival A Source of Inspiration
3/26: Podcamp Ohio
The full title of the article is “The Efficacy of Prophylactic Low-Molecular-Weight Heparin to Prevent Pulmonary Thromboembolism in Immediate Breast Reconstruction Using the TRAM Flap.” The full reference is below.
Deep vein thrombosis (DVT) and pulmonary thromboembolism (PE) are complications that may lead to fatal consequences. For most patients undergoing plastic surgery, these complications are uncommon. There is one exception – abdominoplasty. The reported incidence with this procedure is reportedly 1.1 percent.
The transverse rectus abdominis musculocutaneous (TRAM) flap has the same risk factors as an abdominoplasty (ie obesity, abdominal flap elevation interfering with venous return of the superficial venous system of the pelvis and lower extremity, long surgery time, decrease mobility postop, etc). TRAM flap patients have the additional risk factor of cancer.
Malignancy causes a procoagulant state, with abnormalities in blood flow and vessel wall and blood composition. The overall risk of venous thrombosis was sevenfold higher in patients with malignancy than in persons without malignancy, and the risk of venous thrombosis was highest during the first few months after the diagnosis of malignancy. In breast cancer patients, the adjusted odds ratio for venous thrombosis is 4.9, and up to 15 percent of breast cancer patients present with venous thromboembolism during the course of their disease. Moreover, chemotherapy and hormone therapy, which are unavoidable, are significant precipitants of venous and arterial thrombosis.
The incidence of DVT and PE associated with patients undergoing immediate breast reconstruction with TRAM flaps has been reported to vary from 0.7 to 18.8 percent.
The authors conducted a prospective study of the efficacy of prophylactic use of low-molecular-weight heparin to prevent PE. They did this by looking at 650 consecutive patients who underwent immediate breast reconstruction with TRAM flaps between August of 2001 and April of 2007. Group 1 included the first 450 patients treated prior to February 2006. No medical prophylaxis was administered to Group 1. Group 2 included the 200 consecutive patients treated since February of 2006. This group was given a once-daily dose of 40 or 60 mg of enoxaparin for 7 days (depending on the patient’s weight), from the day of surgery. All patients in group 1 and group 2 wore compression stockings until fully mobilized and began ambulation on the second postoperative day.
Fifty-four consecutive patients in group 1 (group 1c) and 68 consecutive patients in group 2 (group 2c) were routinely checked to detect asymptomatic PE on the third postoperative day. The exams used included serum D-dimer, pulmonary ventilation-perfusion scan, and pulmonary embolism computed tomography
The average age of the patients in both groups 1 and 2 was 42 years. The average BMI was 22.6 kg/m2 in group 1 and 23.6 kg/m2 in group 2. All patients had quit smoking at least 3 weeks before surgery, but 5.7 % of Group 1 patients and 3.5 % of Group 2 were ex-smokers. The average stage of cancer was 1.48 in group 1 and 1.67 in group 2. No patient had any history of coagulopathy, DVT, or PE.
Symptomatic thromboembolism was diagnosed in eight of the 450 group 1 patients (1.8 percent)
Asymptomatic pulmonary thromboembolism was detected in nine of the 54 group 1c patients (16.7 percent) who underwent routine workup for pulmonary thromboembolism.
Neither symptomatic nor asymptomatic pulmonary thromboembolism was diagnosed in group 2 patients.
Although the incidence of symptomatic pulmonary thromboembolism was lower in group 2, the difference was not statistically significant (p = 0.107). In contrast, the incidence of asymptomatic pulmonary thromboembolism was significantly lower in group 2c patients than in group 1c patients
They found the most common symptom of symptomatic PE to be chest discomfort (100 percent), followed by tachypnea, dyspnea, and cough. Most symptoms were developed on the second or third postoperative day.
Concerns are often raised about bleeding-related complications with the prophylactic use of low-molecular-weight heparin. The authors found no increases in significant bleeding-related complications, including transfusion rate.
Clinical observation showed that enoxaparin-treated patients had more apparent bruising at the operation sites and the subcutaneous injection sites.
This is considered unavoidable, and meticulous hemostasis is required during every procedure throughout surgery, especially at the muscle stump and the deepithelialized flap surface.
The Efficacy of Prophylactic Low-Molecular-Weight Heparin to Prevent Pulmonary Thromboembolism in Immediate Breast Reconstruction Using the TRAM Flap; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 9-12; Kim, Eun Key M.D.; Eom, Jin Sup M.D., Ph.D.; Ahn, Sei Hyun M.D., Ph.D.; Son, Byung Ho M.D., Ph.D.; Lee, Taik Jong M.D., Ph.D.
Other Blog Posts of Interest:
The next edition (218) of SurgeXperiences will be hosted by Vijay, Scan Man’s Notes, on March 1st.
Scan Man is a radiologist in India. He has a great blog. I hope you will check it out.
The deadline for submissions is midnight on Friday, February 27th. Be sure to submit your post via this form.
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.
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.
Like many people, I love coffee, so it was nice to see this article on the "coffee consumption of women" published online before print in the February 16 issue of Circulation: Journal of the American Heart Association. (photo credit)
My family has a history of stroke and high blood pressure, so I was even happier to find that my coffee drinking helps protect me from strokes.
So, yes, I’ll have another cup of coffee.
Dr Esther Lopez-Garcia and colleagues analyzed data from a prospective group of 83 076 women in the Nurses' Health Study. At the beginning of the study none of the women had any history of stroke, coronary heart disease, diabetes, or cancer. The researchers first assessed coffee consumption in 1980 and then followed up every 2 to 4 years through 2004.
They found coffee drinking to be linked to a modest reduction of stroke risk among women. Drinking three cups of coffee a day reduced the risk by nearly 20 per cent compared to drinking less than one cup of coffee a month.
Yes, I’ll have another cup of coffee.
The study documented the number and types of strokes that occurred in these women during the years 1980 – 2004. A total of 2280 strokes occurred (426 were hemorrhagic, 1224 were ischemic, and 630 were undetermined).
The relative risks of stroke decreased as the amount of coffee consumed went up. The relative risk of stroke in a woman who drank less than one cup per month was noted to be 0.98 compared to a relative risk of 0.81 for a woman who drank 2 to 3 cups of coffee per day.
The noted protection held even in women with high blood pressure, hypercholesterolemia, type 2 diabetes, and smokers. Other drinks containing caffeine such as tea and caffeinated soft drinks were not associated with stroke.
I’ll pass on the coke, but I’ll have another cup of coffee.
For more information on Strokes:
National Stroke Association
Coffee Consumption and Risk of Stroke in Women;
Esther Lopez-Garcia, Fernando Rodriguez-Artalejo, Kathryn M. Rexrode, Giancarlo Logroscino, Frank B. Hu, and Rob M. van Dam.; Circulation published online before print February 16, 2009. doi: 10.1161/CIRCULATIONAHA.108.826164
I finished the quilt I began so many years ago, then at the end of 2008 took apart and redid. I had already sewn the squares which are 16.5 in finished (after re-trimming) before I read the very nice comment by Celeste.
Anytime I do hand appliqué, I cut the blocks larger to allow for the inward shrinkage. I then use a lot of Magic Sizing to stiffen them when pressing, and square them up. Because you don't have an equal amount of white space at the edges of all of your blocks, I would suggest that you do some kind of pieced sashing that has a light background. Obviously garden maze sashing comes to mind for floral appliqué, but a twisted ribbon would look good and so would an appliqued sashing. But the light background (similar to your blocks) would help keep the more filled blocks from looking hemmed in by a dark sashing like you had. I would also lean towards a wider sashing than what you had; with only four blocks I think it will set them off better, and it will set the stage for you to consider a wider and possibly more dramatic outer border.
I had initially intended for the quilt to “look” like a window that I was viewing a different season through each of the four panes. I stuck with that choice, but love the one options that Celeste made.
The finished quilt is 49 in X 49 in. It was hand appliqued but the blocks were sewn together by machine. The quilting was done by machine.
She is also correct about the difference in the unequal amounts of white space. If I chose the blocks again, I would have chosen something other than the Dresden plate for winter. I might have still used the “wreath” of leaves for fall, but scaled it to leave more white space outside the leaves.
Overall, I like the quilt, but mostly am pleased that I finished it.
The other posts done on this quilt:
Dresden Plate Block – my winter
Windblown Tulips Quilt Block – my spring
Wild Rose Quilt Block– my summer
Wreath Quilt Block – my fall
In this day and age when physicians are facing being rated like the local plumber or restaurant on Zagat, it astounds me that anyone would allow a non-physician to perform cosmetic enhancement “injections” in their home. That seems to be what women in Florida have done to the detriment of their health (ABC Action News).
Two women who wanted cosmetic injections to enhance their bottoms are now recovering in a Town N' Country Hospital with severe infections.
Deputies say Andrea Lee and Zakiya Teagle thought they were getting injections that were safe and would provide them with the appearance they wanted. Instead, the person who injected them apparently is on the run and detectives want to find her.
Hillsborough County Sheriff's office says Sharhonda Lindsay of Tampa is wanted for practicing medicine without a license. A warrant for her arrest was issued Monday.
They say Lindsay injected the women's buttocks several times and was paid hundreds of dollars for her efforts. But after leaving her home, the two were in so much pain and had to go to the hospital for treatment.
On Monday night, one of the two women was in critical condition after her kidneys stopped functioning.
While there are safe ways to cosmetically enhance buttocks, silicone injections is not one of them. Silicone injections into soft tissue in the United States has been illegal for many years now. Silicone injections into the face and breasts were once used for enhancement in those areas, but led to many disfiguring problems.
When liquid silicone is injected into soft tissue (face, breasts, buttocks) it can migrate to other areas. The body often reacts to the silicone by forming benign tumors called siliconomas.
Good physicians won’t do liquid silicone injections. They will use fat injections. They will do buttock implants.
Safe methods for buttocks enhancement include:
Combination of the Above
It is important to go to a well trained plastic or cosmetic surgeon. Do not go to a friend who offers to do the injection in their home.
There is little in the literature regarding management of “significant hemorrhage from fractures of the midface.” The authors of this article (full reference below) did a retrospective study to try to look at this complication and its management.
Hemorrhage from facial fractures can threaten life by causing hypovolemic shock or by contributing to airway obstruction. They found no established definition of massive hemorrhage from facial fractures, so devised the following:
Fracture of the midface or skull base plus hemorrhage into pharynx
* Causing tachycardia (pulse rate >100) and hypotension (systolic pressure <100) with no other cause identified, or
* Necessitating acute transfusion with two or more units of packed red cells, or
* Where blood loss from that source was measured as greater than 500 ml.
Using the above definition, the authors went through the discharge data system (Australian health care system) to identify all those patients (January 1, 1984, to December 31, 2003) who had been discharged with diagnosis codes for malar bone, maxillary, or skull base fractures (mandible fractures were not included in the population). This list was then cross-referenced to include a diagnosis code of epistaxis or a procedure code such as arrest of hemorrhage, nasal packing, or blood transfusion. The medical records of these patients were then examined to see if they met the above definition of massive hemorrhage from facial fracture.
In addition to the retrospective study, the details of any new cases of massive hemorrhage in facial fractures were documented over an additional 1-year period. The incidence of cases was calculated for both the 20-year period and the subsequent 1-year period. The clinical presentation, management, and outcome data of cases were analyzed as a whole, with those of the retrospective cases being combined with those of the recent cases.
The retrospective study included 4501 patients with codes for maxillary, malar, or skull base fractures. They found only 50 patients with codes for both facial fractures and at least one of the codes indicating bleeding. Only 15 of these met the definition of massive hemorrhage from facial fractures. That gives an incidence of 0.33% facial fracture patients with massive hemorrhage over the twenty year period.
During the one year period, 226 patients with midface or skull base fractures were treated. Four of these had massive bleeding or an incidence of 1.77 percent.
In the combined data set, seven of the 19 patients died during the hospital admission in which they had the facial fractures. The patients who died had multiple injuries so it is difficult to attribute the cause of death to one pathology alone.
Most patients were male with a median age of 48 years (range, 18 to 83 years). Most common cause of injury was motor vehicle accident. Most patients had other injuries besides the facial fracture, including significant head injuries.
Most patients had significant hypovolemia on presentation.
Descriptions of facial fracture patterns
Five patients were described as having skull base fractures or Le Fort III fractures, with an additional three patients reported as having fractures of individual bones of the skull base (sphenoids or ethmoids). Four of these eight patients died. Of the 10 patients identified with a Le Fort fracture, five died.
The authors discuss the following at important aspects of management:
1. Recognition of Facial Fracture Hemorrhage as Significant
2. Arrest of Hemorrhage Method
In three patients, arrest of hemorrhage was attempted with nasal/oral/pharyngeal packing alone. All three patients died. As all three had multiple injuries, the contribution of the facial fracture hemorrhage to death was difficult to quantify.
Ten patients had insertion of balloon catheters of some sort--Foley catheters or Brighton epistaxis catheters--and no vessel ligation. Four of these patients died; again, each of the deaths occurred in the context of polytrauma.
Five patients had ligation of a vessel, either the external carotid, maxillary, or anterior ethmoidal, with or without other measures. None of these patients died. No patients had radiological embolization of vessels to the face.
3. Airway Management
4. Blood Transfusion
All patients were given a transfusion of packed red cells. The median number of units given was 9 and the mean number was 10.
Their Procedure for Arrest of Massive Facial Fracture Hemorrhage
Massive hemorrhage from facial fractures is an under-recognized and inconsistently managed phenomenon. Although low in incidence, its timely recognition and better management may reduce the high mortality rate in this group of patients.
Article is worth reading.
Massive Hemorrhage in Facial Fracture Patients: Definition, Incidence, and Management; Plastic and Reconstructive Surgery:Volume 123(2)February 2009pp 680-690; Dean, Nicola R. Ph.D., F.R.A.C.S.(Plas.); Ledgard, James P. M.B.B.S.; Katsaros, James M.B.B.S., F.R.A.C.S.(Plas.)
When I was contemplating hosting Grand Rounds, did I realize that I was hosting a compilation of serious interdisciplinary dialogue relating to the practice of health care?
Did I understand the enormity of the task I had chosen to undertake?
Heck yes I did!
I chose to use a “Napoleon Dynamite” theme anyway as that is pretty much the coolest movie ever made.
If you’ve seen it, you’ll get it. If you haven’t, you’ll think I’m nuts (but I have great nunchuk skills….)!
So grab your coffee, and get ready for a good read!
Or, as Napoleon’s Grandma says, “just make yourself a dang quesa-dilluh!”
Welcome to Grand Rounds…
Congratulations to all the nominees. Go vote for your favorite here. Voting is open until February 20th.
As you know, Australia has had horrible bushfires recently with loss of entire communities, businesses, homes, and lives. Knowing I quilt, Dr Cris sent this tweet out. I’ve made a few blocks already. Hope some of you will do the same.
Check out this story of Dr Eugene Alford in the March 2009 issue of Reader’s Digest, “His Own Medicine”. He is a facial plastic surgeon at Methodist Hospital in Houston, TX. He was paralyzed in an accident, but with a lot of physical therapy and community/family support has made it back to the OR as the surgeon. (photo credit)
Dr. Willem Johan (Pim) Kolff, one of the most prolific inventors of new medical devices, has passed away at age 97 in Philadelphia. Dr Kolff led a long and productive life, and through his genius he saved and greatly improved the lives of thousands of others. From external dialysis machines to the CardioWest artificial heart, Dr Kolff was one of the revolutionaries that successfully introduced practical devices to the medical world.
A Repository for Bottled Monsters has this announcement:
On Saturday, February 28, from 2-5 p.m. the NMHM will host a Knitting for Marines charity event to make and distribute helmet liners to Marines stationed in Iraq and Afghanistan. The liners help to protect our Marines and keep them warm during the harsh winters in these countries.
If you don't know how to knit in the round, this is a great time to learn. Instructors will be on site to help you through the project. If you are an experienced knitter and wish to get an early start on the project, you may download the knitting pattern.
You can check out the archives of his Blog Talk Radio show. Here is the upcoming schedule:
Acute compartment syndrome of the hand is an emergency and requires prompt surgical decompression. This article (the first reference below) is a cadaveric study aimed at identifying the myofascial compartments of the hand. As they point out
Few studies have outlined the myofascial compartments of the hand. The standard anatomy texts do not show actual anatomical specimens but instead rely on diagrams and figures to outline the various compartments. These include the thenar, hypothenar, adductor, and interosseous compartments, each encased in fascia that extended from one metacarpal to another
The ten anatomical compartments of the hand include (photo credit)
The authors dissected fourteen fresh-frozen cadaveric hands. They found no distinct tough fascia completely surrounding any of the intrinsic muscles, but instead thin filmy fascia that partially encases some of the muscles.
There was no well-defined tough fascia overlying the thenar muscles, the hypothenar muscles, or the adductor pollicis.
Areolar tissue was present between the individual thenar and hypothenar muscles.
A distinct band of fascia was noted over the entire length of the ulnar three dorsal interosseous muscles.
A band of fascia was noted over the distal portion of the palmar interossei but not over the proximal aspect.
The above findings were found in all 14 specimens.
A layer of loose areolar tissue was noted over the dorsal aspect of the first web space in eight specimens, whereas a distinct band of fascia was noted overlying the first dorsal interosseous muscle in the remaining six.
Interesting findings, but doesn’t explain why it is necessary to do the fasciotomies in each and every compartment. Does the skin constrict that much? Maybe.
Myofascial Compartments of the Hand in Relation to Compartment Syndrome: A Cadaveric Study; Plastic and Reconstructive Surgery:Volume 123(2)February 2009, pp 613-616; Ling, Marcus Z. X. M.B.B.S.; Kumar, V P. F.R.C.S.
Beware: Compartment Syndrome of the Hand; JNZMA, Feb 11, 2005, Vol 118, No 1209; Warren Leigh, Vasu Pai
Compartment Syndromes of Hand and Forearm; Wheeless' Textbook of Orthopaedics; Last updated by Clifford R. Wheeless, III, MD on Sunday, December 28, 2008 8:31 pm
Compartment Syndrome, Upper Extremity; eMedicine Article, July 27, 2007; Stephen Wallace, MD and Douglas G Smith, MD
It’s the Learning and Teaching Surgery Edition
Welcome to SurgeXpereiences, the fortnightly blog carnival about all topics surgical. The tentative theme for this carnival is teaching and learning surgery.
As always, there is evidence that Surgeons require good teaching. Some of them certainly make bad decisions, when left to their own devices. See this report by Medical Quack, and reports on our “favourite” Queensland surgeon who is facing trial this month, Jayant Patel, and probably shown in this one, too Dubai surgeon sues hospital. It is further evidenced by the need for articles like this How to avoid surgical errors
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.
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.
Here are three Wonky Star Blocks that I have made and sent.
There are two addresses to mail finished blocks:
US APO address - "local" to those mailing from the US, so postage will be much less expensive:
PSC 276 BOX 89
APO AP 96548 USA
Australian street address:
18 Forrest Crescent
Alice Springs, NT 0870
This baby quilt is for our blog friend, Buckeye Surgeon. His wife will be having a baby soon. I have no idea whether the baby is girl or boy. I hope I made it interesting for either, though I admit I found myself hoping the baby will be a boy. Mostly I hope the baby is healthy.
I stumbled across this pattern while browsing through one of my quilting books. It was a loose page I had saved from a flyer years ago. It was called “Sunday Funshine Quilt”. I can’t find who to credit it to. They called the basic block – Funshine Block. Think nine-patch. The top and bottom row of the block is 2.5 in X 6.5 in rectangle. The center row is made of three 2.5 in squares. The finished block is then 6 in.
The quilt measures 42 in X 48 in. It is made of scrapes and partial fat quarters. It is machine pieced and quilted.
Here is a close photo to show some of the interesting fabrics. I love the motorcycle tire in the center of the blue batik block. I love the football player, the lion, and the “feet”.
Here’s another detail shot. Here you’ll find a steer, a cowboy, an angel, and the front end of a race car.
This is the back. I found this lovely flannel fabric in the remnant bin. It was just over a yard of fabric, not quite enough for the back. I sewed some dark green/brown flannel to each end. Appropriate for Valentine’s Day – don’t you think?
Not sure how I got on the list to receive Emergency Medicine journal, but I always look through it before I recycle it. There are often decent articles in it. The one referenced below is a nice quick review on the problem of mammal bites. This is an issue most doctors will encounter at some point in time.
About 1% of emergency department and urgent care visits each year are for mammal bite injuries or their complications. Ten to 20 people die each year from mammal bites. In 2006, 310,710 injuries from dog bites alone were reported to the Centers for Disease Control and Prevention. The actual number of bite wounds from all mammals is estimated to be around 2 million each year, but that figure underestimates the true incidence because most animal bites are unreported.
Animal bite injuries come in many forms: lacerations, punctures, crush injuries, tears, rips, avulsions, fractures, hemorrhage, and contusions. The type and severity of the injury will depend on the location of the bite, the animal involved, and size of the patient.
More than two-thirds of bite injuries occur in children younger than 10 years old—boys more often than girls. Children most commonly pre-sent with bite wounds to the face, neck, and head. Adults more commonly present with bites to the extremities.
The article gives helpful “History and Physical Exam Tips”
A thorough history of the event includes asking about the timing of the injury, the kind of animal involved, its health history (including vaccination status and current health), and its behavior. Other important information about the animal includes whether it can be observed or captured.
The article gives a nice review of principles for reducing the risk of infection. As with all wounds, standard wound care applies. This means copiously irrigate and debride as needed.
Bites are tetanus-prone wounds. Review the patient’s immunization records. Give updates, etc as needed.
Most wounds can be closed primarily. It’s expected that a small percentage of wounds will become infected and require early suture removal. Inform patients that wound infections may occur in spite of the appropriate care. Advise all patients at discharge to look for signs of infection, such as redness, increasing pain, and purulent drainage.
Some bite wounds have a higher risk of infection.
Animal Bites With a High Risk for Infection
• crush injuries
• hand wounds
• puncture wounds
• wounds with extensive devitalized tissue
• heavily contaminated wounds
• prolonged time from injury to treatment:
6–12 hours on the body
12–24 hours on the face
The article points out some specific considerations to keep in mind.
Dog bites. A big fear with dog bites is rabies, but the actual incidence among these dogs in the United States is low. Similarly, few dog bites actually lead to infection.
However, significant bites are at risk for infection, which is usually polymicrobial. About 50% of infected dog bites involve Pasteurella canis. The first-line antibiotic is amoxicillin/clavulanic acid 875 mg orally twice daily for adults and 10 to 15 mg/kg orally three times daily for children (see table below). Duration of therapy is not clearly established.
Cat bites. In contrast to dog bites, most cat bites do become infected.
Pasteurella multocida is present in 70% to 90% of the infections. Antibiotic post-exposure prophylaxis that is effective for P. multocida is recommended for all cat bites; unfortunately, P. multocida is resistant to clindamycin, dicloxicillin, cephalexin, and erythromycin. The first-line antibiotic is amoxicillin/clavulanic acid 875 mg orally twice daily in adults, 10 to 15 mg/kg orally three times daily for children. Duration of therapy is not clearly established.
Cats have the highest incidence of rabies of all domestic animals in the United States. However, transfer to humans remains rare.
Primate bites. A subgroup of primates called the macaques (rhesus and green monkeys) carry B virus (Cercopithecine herpesvirus 1), usually by the age of 2.
Though asymptomatic in the macaques, B virus causes fatal encephalitis in humans; 24 of the 25 humans known to be infected have died. The incidence of transmission is unknown, but it has been documented to occur from even trivial wounds. Due to the high mortality, post-bite prophylaxis is recommended for any macaque bite. First-line therapy is valacyclovir 1 gram orally every 8 hours for 14 days.
Rodent and rabbit bites. Rodents, rabbits, and hares carry Francisella tularemia and can transmit this to humans through bites. The CDC does not recommend routine prophylaxis for tularemia from the bite of a rodent.
Domestic and wild rats in the United States carry and transmit Streptobacillus moniliformis, which causes rat bite fever. The CDC recommends post-bite prophylaxis after wild or domestic rat bites.The first-line antibiotic is amoxicillin/clavulanic acid 875 mg orally twice daily for adults and 10 to 15 mg/kg orally three times daily for children. Duration of therapy is not clearly established.
Overall, a very nice review article. Especially good for students and residents. The article includes tables of appropriate antibiotics and dosages.
Related Blog Posts:
Assessing and Managing Mammal Bites; Emerg Med 41(1):35, 2009; Lisa D. Mills, MD, and John Lilley, MD
First off, let me say I have never seen this complication of sulfonamides. I was only vaguely aware that it existed. A patient came in to discuss a cosmetic procedure. Like always, I was going through the allergy section. She had marked yes on the sulfa drugs. I asked what kind of reaction. I want to know if it was a true problem or just an unwelcome side effect.
She then told me about her son who died of acute hepatic failure from a reaction to Bactrim (Sulfamethoxazole/Trimethoprim), and how a few years after his death she got very ill after taking Bactrim. So now their family refuses to take sulfa drugs. It prompted me to do a review.
Sulfamethoxazole/Trimethoprim (SMX/TMP) is a commonly used antibiotic for respiratory, gastrointestinal and urinary tract infections caused by a range of aerobic gram-positive and gram-negative bacteria. It also has activity against Listeria monocytogenes, Nocardia and Pneuomcystis jiroveci.
SMX/TMP is generally well tolerated in non-HIV-infected patients. Adverse reactions occur in this group in approximately 6 to 8 percent of individuals. In comparison, the adverse reaction rate is as high as 25 to 50 percent in HIV-infected patients and many of the reactions are severe.
The most common adverse reactions include nausea, vomiting, anorexia, dermatological reactions such as pruritis, urticaria and less commonly Steven Johnson Syndrome.
Life-threatening adverse reactions include neutropenia, exfoliative dermatitis (a severe skin disorder with generalized erythema and scaling) and toxic epidermal necrolysis (an acute severe reaction with widespread erythema and detachment of the epidermis). Acute liver failure has only been reported in a few cases worldwide, and has been attributed to the sulphonamide component of the drug.
The sulfamethoxazole component of SMX/TMP is responsible for most of its' side effects including liver failure.
Three forms of SMX/TMP induced liver damage have been described.
2) mixed hepatocellular cholestatic
3) bile duct injury with ductopenia or Vanishing Bile duct syndrome
The onset of symptoms usually occurs within a few days of exposure, but can take up to a 1–2 months. Patients will usually present with nausea, vomiting, jaundice, and pruritis (if cholestatic). Liver function tests (LFTs) may show a hepatocellular or cholestatic pattern depending on the type of injury. Patients might have other feature of an allergic reaction such as skin rash, eosinophilia.
Diagnosis is suspected from the clinical presentation, and absence of other causes.
The severity of SMX/TMP induced liver injury can range from mild symptoms with elevated liver enzymes to fulminant hepatic failure with hepatic encephalopathy and coagulopathy. Outcome can be favorable with spontaneous resolution or unfavorable leading to death.
Treatment is generally supportive, liver transplantation has been successful for both fulminant hepatic failure and vanishing bile duct syndrome
Acute Liver Disease Associated with Erythromycins, Sulfonamides, and Tetracyclines; Annals of Internal Medicine, Vol 119, Issue 7, Part 1, pp 576-583, Oct 1993; Jeffrey L. Carson; Brian L. Strom; Amy Duff; Anand Gupta; Michele Shaw; Frank E. Lundin; and Kiron Das
Case Report: Sulfamethoxazole/Trimethoprim induced liver failure: a case report; Cases Journal 2008, :44doi:10.1186/1757-1626-1-44; Salaheldin Abusin, Swapna Johnson
Harrison’s Online; Chapter 299 (Merck’s)-- Trimethoprim-Sulfamethoxazole Hepatotoxicity (Idiosyncratic Reaction)
Welcome to Grand Rounds. It's been quite some time since THCB hosted the medical blogosphere's major compendium. So sit back and enjoy a stroll through the gardens of medical and health care obsession.
It's still a fresh political season, so we start with the wonks:
I will be participating in the St Baldrick's program to raise funds for pediatric cancer research. I will be shaving my head at Fado's Pub in Chicago on March 13, sacrificing my beautiful locks to the cause of finding cures for these terrible diseases. Last year, we did the same, and Nathan's Network raised just about $40,000. You, my readers, were instrumental in helping us achieve that goal.
So, again, I ask you to consider donating whatever sum you can -- simply click on the image below and it will take you to the secure online donation site. The top donor will get first swipe with the razor, should he or she care to come to Chicago! All donors will receive an image of my glistening bald scalp and an extra helping of good karma.
The third edition of Change of Shift (Vol 3, No 16) for 2009 is hosted by Digital Doorway! It’s the “fish bowl” edition. I hope you will check it out (photo credit). You can find the schedule and the COS archives at Emergiblog.
In the days leading up to hosting this edition of Change of Shift, I gave a great deal of thought to the phenomena of the internet, blogging, Twitter, iPhones, Facebook, and the many technological advances that now keep us all connected and communicating.
That said, as much as I love these manifestations of our Digital Age, I also see these forums as proverbial fish bowls in which we all stew ourselves in the waters of public communication, often rendering ourselves vulnerable and naked as the observing masses watch our every move.
Welcome to the inaugural edition of Palliative Care Grand Rounds, a monthly blog carnival bringing you the best and most interesting blog posts about hospice, palliative care, death and dying, grief, quality of life, communication in the medical arena, and anything else that strikes the fancy of the host that month.
If you are interested in becoming one of the upcoming hosts, please comment or email me at ctsinclair @t g-m-a-i-l d0t c0m. Here is the website with the archives and upcoming hosts.
Rhinoplasty Surgery Blog has a nice post titled "Pablo Picasso's Girl in the Mirror: The Agony of Imagined Ugliness". (photo credit)
Most clinicians involved in the treatment of patients with facial deformities will encounter the patient who is excessively concerned with a minor or imperceptible defect in their appearance or patients who reveal extreme dissatisfaction despite good treatment results. In cases in which such a preoccupation with appearance causes the patient marked distress in their social or occupational functioning, the patient may have nondelusional dysmorphophobia, also known as body dysmorphic disorder (BDD).
Ant Ears is back!
It has been some time since I last posted. Busy trauma rotation, holidays, ABSITE, killer call schedule - suddenly 3 months went by.
You can check out the archives of his Blog Talk Radio show. Here is the upcoming schedule:
2/19: From Medskool