Sunday, October 31, 2010

War Eagle Cornbread Quilt

I bought this cornbread mix specifically so I could have the fabric bag it came in.  The graphics with the eagle includes the recipe for the cornbread.  I used a lovely navy fabric for the border which features either wheat or corn (not sure which).  I machine pieced the quilt, then hand quilted it.

The quilt is 8.5 in X 10 in.  The back includes a 2 in sleeve to facilitate hanging it.  I have listed it on Etsy for anyone interested.

Friday, October 29, 2010

Simple Baby Quilt

This is a very simple baby quilt made using 6 in squares.  It is scrappy using fabric from other projects.  The quilt is machine pieced and quilted.  It measures 36 in X 42 in.  It was given to a friend of my husband’s.

This photo shows a weight-lifting alligator, cars, a school house, and a cowboy.
Here you can find dogs, Eeyore, horses, Indians, a lion, and more.
Here you find more cowboys, zebras, a ladybug, Pooh and Tigger.
The back of the quilt is a simple fabric with red stars.

Thursday, October 28, 2010

Fiorina’s Infection Highlights Reconstruction Complications

The news report of California Republican U.S. Senate Candidate Carly Fiorina’s recent hospitalization due to an infection related to her breast reconstruction is an opportunity to talk about the risks of complication associated with breast reconstruction surgery.

Fiorina was diagnosed with breast cancer diagnosis in February 2009.  She was treated with chemotherapy, radiation and a double mastectomy.  I found several articles that note she had her reconstructive surgery at Stanford University Medical Center, the San Jose (Calif.) in July 2010, but none mention the reconstruction technique used.

My guess would be implant based reconstruction considering how quickly she returned to campaigning.  Recovery time for a TRAM flap (free or pedicle) or any other flap based reconstruction would have been much longer.

The chemotherapy and radiation put her at increased risk of surgical complications.  It’s all a balancing act.  Weighing the need/desire for reconstruction against the risks.  Treatment of the breast cancer is always the first priority.

As noted by in the eMedicine article (1st reference below)

The occurrence of complications using expander-implants can exceed 40% in published studies. However, despite a significant rate, the complications themselves are usually minor and do not prevent completion of a satisfactory reconstruction. In experienced hands, good to excellent aesthetic outcomes can be obtained in more than 80% of patients.

The 40% includes every little complication that can occur:  capsular contracture, infection, wound healing issues, seroma/hematoma, assymetry, poor implant position, etc.

Breaking it down better is the table found from the Mentor Large Simple Trial data that lists the complications that occur within 3 years.

Additional Operation (Reoperation) 40%
Loss of Nipple Sensation 35%
Capsular Contracture III/IV or grade unknown 30%
Asymmetry 28%
Implant Removal 27%
Wrinkling 20%
Breast Pain 17%
Infection 9%
Leakage/Deflation 9%
Irritation/Inflammation 8%
Delayed Wound Healing 6%
Seroma 6%
Scarring 5%
Extrusion 2%
Necrosis 2%
Hematoma 1%
Position Change 1%

 

What these numbers don’t do is individualize the risk.  You can’t tell from these numbers who had only radiation, who had only chemotherapy, who had both, which ones smoked, who had diabetes, etc.  All of these things increase the risk to the individual.

 

 

Related Post:

Infected or Exposed Breast Prosthesis (Sept 1, 2010)

Patient Satisfaction Following Breast Reconstruction Using Implants (June 7, 2010)

 

REFERENCES

Breast Reconstruction, Expander-Implant; eMedicine article, October 2009; Jorge I de la Torre, MD, FACS, Luis O Vasconez, MD, FACS

Breast Reconstruction Overview; eMedicineHealth

About Breast Reconstruction; Cancer Help UK

Wednesday, October 27, 2010

Dynamed/Skyscape

A week ago I attended a lunch lecture on Mobile Medical Apps given by Krystal Boulden, MLIS at UAMS.  I knew about most of the ones she talked about:  Epocrates, Clini-eGuide, PubMed on Tap, PubMed for Handhelds, and RefWorks.  Of those, I only use Epocrates.

The one I didn’t know was the first one she highlighted:  Dynamed (the actual app is Skyscape).

DynaMed - Clinical reference tool provided by the University of Arkansas for Medical Sciences (UAMS) Area Health Education Centers' Libraries (AHEC), Arkansas Children's Hospital Library, and the UAMS Library. Registration is required for access and renewal is required annually. Training is available through the Area Health Education Centers' Libraries and the UAMS Library. To register for DynaMed click here. To access DynaMed click here.

DynaMed is free to use, but registration is required.  It is evidenced-based, often with links to related articles.  It provides information related to the disease, diagnosis, and treatment.  I have only recently registered and been given my user/password, but with the limited “playing” around I have found it full of useful information. 

The medical app, Skyscape, is free for download from iTunes.

Choose content from top publishers, current guidelines, drug guides, interactive algorithms, calculators and much more.

Skyscape can help you find the information you are looking for:

Table of Contents Search

Incremental Search

SmartSearch™

History

Related Topics

SmartLink™

I haven’t downloaded the app so I can’t give you a personal review.  If anyone has used it, what do you think?

 

Looking around the UAMS Library website it appears I have not been taking full advantage of the resources they offer:

Online Resources

·  eResources | eJournals

·  eBooks | eReserves

·  Clinical Resources

·  UAMS Library Catalog

·  Mobile Devices

·  HRC Digital Collection

· Image Resources

 

On twitter:

@UAMS

@UAMSlibrary

 

Shout out to a couple of guys from MD2P.net whom I met at the meeting:  Simon Lee (@simonslee) and John Malone (@JJMal_One )

Tuesday, October 26, 2010

Shout Outs

Notes from Spice Island is the host for this week’s Grand Rounds! You can read this week’s edition here.

Welcome to this Edition of Grand Rounds. I'm honored to be hosting for my first time. The topic is education and lessons learned. I hope you enjoy!  ……….

Don't forget to check out Grand Round next week with a special election themed edition, Dr. Wes is hosting. Enjoy your Tuesday!

……………………………………….

While this Better Health article by Barbara Ficarra, RN focuses on cancer prevention news article, the same tips can be of help with any medical news articles:  Cancer Prevention: How To Sift Through The Headlines

Most of us can’t keep up with all the new ways to avoid cancer. Thanks to the Internet, we now have an unlimited supply of cancer knowledge at our fingertips. But, how can we filter out the good, the bad and the questionable?

Below are steps to help you tease out the facts when reading that next big news story on preventing cancer.

Says who?

Don’t just take the writer’s word for it. Dig a little deeper to find out the source behind the hype. The American Cancer Society says you should ask yourself these questions when reading an article:  ………….

Knowing the answers to these questions can help you decide on where you need to go to seek more details about the study findings. Visit the source of the information to learn more about how this new substance or method was tested.  ………..

…………………………………….

From twitter: RT @doctorwes: Electronic era part of problem? RT @AbbieCitron RT @Lawcats RT @MatthewBrowning: Missed Nursing Care- http://bit.ly/b5fEj2

The article, Missed nursing care: View from the hospital bed (Part One), is by  Beatrice J. Kalisch

Health care providers often assume they know what inpatients are experiencing. How different the view is from the hospital bed. Suddenly, the paradigm is flipped. Insights gained about hospital care from that vantage point can be quite astounding and must be examined if inpatient care is to improve. It is toward this end that I share my experience as an inpatient for seven days in an acute-care U.S. hospital. I was out of town and a longtime friend took me to the emergency department (ED).   …………….

………………………….

Via twitter: @ milblogging Military Blogs

U.S. Navy releases Social Media Handbook (View Online) http://tinyurl.com/2v6w37o

…………………………..

I like NPR, Elton John, and Leon Russell which made this segment NPR did last week very enjoyable for me:  Elton John And Leon Russell Reunite On 'The Union' 

Elton John and Leon Russell's paths seemed fated to cross: Both grew up at the piano, learning to play as little boys. Both played piano in bars while in their teens, and both started their careers as piano players for hire. But, according to John, there's one important difference.

"He is a better piano player than I am," John says. "As far as gospel and stuff like that, that's why I wanted to make this album. He is my idol."   ……

and this one:  First Listen: Elton John And Leon Russell, 'The Union' which gives you the opportunity to listen to some of the songs on the album.

………………………………….

Dr Anonymous’ show will be about FMEC Mtg. The show begins at 9 pm EST.

Upcoming shows:

10/30 : On Location

You may want to listen to the shows in his Archives. Here are some to get you started:

GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan



Monday, October 25, 2010

Team Work

There’s an article in the Oct 20, 2010 issue of the Journal of the American Medical Association (JAMA) which discusses surgical team training and team work in the operating room.

Most surgeons have crews or individuals in the operating rooms they prefer to work along side.  Things just go smoother.  We work more as a team, more as one.

Why?  Personalities.  Communication styles that work well together.  Skills that compliment.  Each person knows and does their job, not trying to do someone else’s.  Each knowing that even the smallest task is important to the whole.

Ideally, we could create teams like this at all times in the operating room.  In reality, its not so easy.  Change in personnel happens.  Team members get sick, so there is great need for cross-training and flexibility.  Personnel (including surgeons) need to be able to work with these changes.

I know currently the comparison is to racecar teams that change the tires, etc with great efficiency or the aviation industry with their check lists.  While we should learn from these industries, we must not forget that medicine is far more diverse. 

Surgeries are not all the same.  The cars are.

Ask your personnel.  I know OR nurses and scrub techs who detest certain surgeries and try very hard not to be in those rooms.  Some like eye surgeries.  Some like orthopedics.  Some like the laparoscopic cases.  Others do not.  Others even after doing similar cases with you multiple times, never seem to pay enough attention to be able to “anticipate” what comes next.

The really good OR nurses and scrub techs will put aside their distaste for the procedure (or surgeon) and function within the team framework.  Others will let their boredom distract them.

In the racecar industry, the guys changing the tires are thrilled to be there.  Thrilled to be part of it all. 

We should strive to work as a team.  We should each learn our job and give it our best.  Like all teams, there have to be second and possibly third strings for backup when a team member is absent (personal sickness, family illness, jury duty, etc). 

The study’s lead author Dr. James Bagian is a former NASA astronaut.  The VA training took a page from the aviation and the nuclear power industries, which have used checklists and improved communication to reduce risks.  The adoption of surgical team training saw a mortality rates drop from 17 deaths per 1,000 cases to 14 deaths per 1,000 cases.

The Medical Team Training program includes 2 months of preparation and planning with each facility's implementation surgical care team. This is followed by a day-long onsite learning session. To allow surgical staff to attend as a team (surgeons, anesthesiologists, nurse anesthetists, nurses, and technicians), the operating room (OR) is closed.

Using the crew resource management theory from aviation adapted for health care, clinicians were trained to work as a team; challenge each other when they identify safety risks; conduct checklist-guided preoperative briefings and postoperative debriefings; and implement other communication strategies such as recognizing red flags, rules of conduct for communication, stepping back to reassess a situation, and how to conduct effective communication between clinicians during care transitions.

The learning session included lecture, group interaction, and videos. After the learning session, 4 quarterly follow-up structured telephone interviews were conducted with the team for 1 year to support, coach, and assess the Medical Team Training implementation. Follow-up calls were usually conducted with the OR nurse manager or an OR nurse, a surgeon or chief of surgery, and other staff nurses, and administrative support staff also frequently participated.

 

 

REFERENCE

Association Between Implementation of a Medical Team Training Program and Surgical Mortality; Julia Neily; Peter D. Mills; Yinong Young-Xu; Brian T. Carney; Priscilla West; David H. Berger; Lisa M. Mazzia; Douglas E. Paull; James P. Bagian; JAMA. 2010;304(15):1693-1700.; doi:10.1001/jama.2010.1506

Improving Teamwork to Reduce Surgical Mortality; Peter J. Pronovost, MD, PhD; Julie A. Freischlag, MD; JAMA. 2010;304(15):1721-1722. doi:10.1001/jama.2010.1542

Sunday, October 24, 2010

Make a Block for RSD/CRPS Awareness Quilt

Recently I received an email alerting me of the RSD/CRPS Awareness quilt project.  The RSD/CRPS community wants to increase public awareness of this disease.  From the group’s Facebook page:

Contribute a 12" x 12" patch to be added to the RSD/CRPS Awareness quilt make sure you keep what you want to show 1" away from the borders.

This is for pain awareness help spread the word and make a square.

Mail all quilt panels (squares) to:

RSD/CRPS Awareness Quilt P.O. Box 500915 Malabar, Fl. 32950-500915

Check out our links for information that can help you put your square together...everything from sewing tips to iron on transfers using your printer.

If you have any questions please feel free to drop Troy Walker a message and I'll help you out if I can. Thank you very much for helping to spread awareness of Chronic Pain

And from “OhMyNerves” Blog

The RSD/CRPS Awareness Quilt is an ongoing project and will be until there is a cure, If you have RSD or someone you love has it, please take the time to participate and send in your square for the quilt. Its growing fast and is already attracting some media attention. This project will do more than anything yet to finally get the problem of RSD/CRPS the attention it desperately needs

 

For more information on RSD/CRPS you may wish to start with these two posts of mine:

Complex Regional Pain Syndrome  (Sept 29, 2008)

New Treatment for CRPS?  (February 15, 2010)

Friday, October 22, 2010

Scrappy Diamond Baby Quilt

You may have noticed over the years that I like scrappy quilts.  I like using scrapes of fabric in baby quilts to add interest and encourage discovery.  This one uses scrappy diamonds.  It is machine pieced and quilted.  It is 36 in X 50 in.

The next several photos show details of the quilt.  Here you can find snowmen, rabbits, a squirrel, a dog, and many colors.
In this one you can find an angel, a frog, a bird, the “eye” of a peacock feather, and the moon.
Here you can see a frog, a butterfly, an eagle, a goose, and more.
Here you can see a squirrel, a cowboy, a dog, a skunk.

The back of the quilt uses the same gray fabric as the outer sections.  I have given this quilt to a twitter friend.

Thursday, October 21, 2010

Tuberous Breasts

The latest edition of the Aesthetic Surgery Journal (Sept/Oct 2010) has a really nice article (first reference below) on this tuberous breasts. One of the best things about the article is the great photos, both of the deformity (includes this one to the right) and the corrective procedure.

Another nice thing the article has is the review of the breast’s embryology which is critical to understanding the formation of the deformity (bold emphasis is mine).

The breast originates from the mammary ridge, which develops in utero from the ectoderm during the fifth week. Shortly after its formation (in the seventh to eighth weeks), most parts of this ridge disappear, except for a small portion in the thoracic region, which persists and penetrates the underlying mesenchyme around 10 to 14 weeks. Further differentiation and development of the breast occurs during the intrauterine life and is completed by the time of birth, after which essentially no further development occurs until puberty.

During puberty, the mammary tissue beneath the areola grows with enlargement of the areola, until the age of 15 to 16, when the breast assumes its familiar shape. As a result of the ectodermal origin of the breast and its invagination into the underlying mesenchyme, the breast tissue is contained within a fascial envelope, the superficial fascia. This superficial fascia is continuous with the superficial abdominal fascia of Camper and consists of two layers: the superficial layer (which is the outer layer covering the breast parenchyma) and the deep layer (which forms the posterior boundary of the breast parenchyma and lies on the deep fascia of the pectoralis major and serratus anterior muscles). The deep layer of the superficial fascia is penetrated by fibrous attachments (suspensory ligaments of Cooper), joining the two layers of the superficial fascia and extending to the dermis of the overlying skin and the deep pectoral fascia. Of note is that the superficial layer of this fascia is absent in the area underneath the areola, as can easily be demonstrated by the invagination of the mammary bud in the mesenchyme.

Clinical experience has shown us and other authors that in cases of tuberous breasts, there is a constricting fibrous ring at the level of the periphery of the nipple-areolar complex that inhibits the normal development of the breast. This constricting ring of fibrous tissue is denser at the lower part of the breast and does not allow the developing breast parenchyma to expand during puberty. Histology confirmed the existence of such dense fibrous tissue in the area of this “constricting ring.” Specimens from two of our patients have been examined, and they showed large concentrations of collagen and elastic fibers, arranged longitudinally. We believe this ring represents a thickening of the superficial fascia, as described earlier. Perhaps the two layers of this fascia join at a higher level than usual, or the suspensory ligaments are thicker and more dense.

Tuberous breast deformity is a rare condition that becomes apparent during teenage years as the breast develop. As noted in the embryology description, the deformity is due to a constricting fibrous ring which does not allow the breast to form in a normal shape.

The deformity which was first described in 1976 by Rees and Aston, can be either unilaterally or bilaterally. When bilateral, the deformity may be vary in degree. It has many other names: tubular breasts, Snoopy breasts, herniated areolar complex, domed nipple, nipple breast, constricted breast, lower pole hypoplasia, and narrow-based breast.

A common classification of tuberous breast deformity is the one proposed by Grolleau et al (photo credit):

  • Type I: deficiency of the lower medial quadrant. (A)
  • Type II: deficiency of both lower quadrants. (B)
  • Type III: deficiency of all four quadrants. (C,D)

The only way to correct this deformity is surgery. Even if no implant is needed or desired, the nipple/areolar complex benefits from a periareolar donut-type skin excision, reducing the areola to the desired size, usually 4 to 4.5 cm in diameter.

I agree with the authors that the constricting fibrous ring needs to be divided so the breast parenchyma can assume a more natural shape. When an implant is used, the subglandular or duel-plane position is preferred.

I would encourage reading the full article for more tips.

REFERENCES

Aesthetic Reconstruction of the Tuberous Breast Deformity: A 10-Year Experience; Mandrekas AD, Zambacos GJ; Aesthetic Surgery Journal September/October 2010 30: 680-692, doi:10.1177/1090820X10383397

The tuberous breast; Rees TD, Aston SJ; Clinics of Plastic Surgery 1976;3:339-347.

Breast Base Anomalies: Treatment Strategy for Tuberous Breasts, Minor Deformities, and Asymmetry; Grolleau, Jean-Louis; Lanfrey, Etienne; Lavigne, Bruno; Chavoin, Jean-Pierre; Costagliola, Michel; Plastic & Reconstructive Surgery. 104(7):2040-2048, December 1999.

Aesthetic Reconstruction of the Tuberous Breast Deformity; Mandrekas, Apostolos D.; Zambacos, George J.; Anastasopoulos, Anastasios; Hapsas, Dimitrios; Lambrinaki, Nektaria; Ioannidou-Mouzaka, Lydia; Plastic & Reconstructive Surgery. 112(4):1099-1108, September 15, 2003.

Wednesday, October 20, 2010

The Scar Project

We all know October is breast cancer awareness month.  The pink ribbon is how many think of breast cancer, but as this tweet reminds us all breast cancer is much more serious.

RT @laikas: RT @gfry "Breast cancer is not a pink ribbon" Exhibition has its own site: http://www.thescarproject.org/home.html Impressive!

I had not known of The Scar Project (photo create) prior to reading that tweet on Monday, but I have seen and created many of the scars.  The physical breast cancer scars come from biopsies, lumpectomies, mastectomies, and even the reconstruction.

The Scar Project, photographer David Jay, and all the women who participated are to be commended. 

The SCAR Project is a series of large-scale portraits of young breast cancer survivors shot by fashion photographer David Jay. Primarily an awareness raising campaign, The SCAR Project puts a raw, unflinching face on early onset breast cancer while paying tribute to the courage and spirit of so many brave young women.

Dedicated to the more than 10,000 women under the age of 40 who will be diagnosed this year alone The SCAR Project is an exercise in awareness, hope, reflection and healing. The mission is three-fold: Raise public consciousness of early-onset breast cancer, raise funds for breast cancer research/outreach programs and help young survivors see their scars, faces, figures and experiences through a new, honest and ultimately empowering lens.

The SCAR Project subjects range from ages 18 to 35 and represent the often overlooked group of young women living with breast cancer. (Breast cancer is the leading cause of cancer deaths in young women ages 15-40). They journey from across America and the world to be photographed for The SCAR Project. Nearly 100 so far. The youngest 18.

There was an exhibition of the project in New York this past weekend.   Even though, the exhibition is over, there is a book for sale of The Scar Project. 

Tuesday, October 19, 2010

Shout Outs

Medical Resident's Journey is the host for this week’s Grand Rounds!  You may recall his poem won Dr. Charles Poetry contest.  The theme this week is “uplifting moments in medicine.”  You can read this week’s edition here (photo credit).

Good morning! Thank you for all the submissions which have flooded my inbox over the past week. They kept me going through a stretch of countless overnight shifts in the emergency department, which seemed never-ending and darker than a moonless night. In the midst of stunning fall foliage this October, the vibrant colors of this week’s Grand Rounds reach towards the sky. Take a moment out of the day to live in the present. Listen to the sounds around you, whatever they may be – leaves rustling in the wind, blaring sirens, constant monitors. Sit back, relax, take a long, deep breath and a sip of your favorite morning drink. Take in the flying kites, subtle music, and silver linings of today’s indulgence: Uplifting Moments in Medicine.  ………….

……………………………………….

I hope you will all read Dr. Rich’s recent post:  Medical Ethics and the Amish Bus Driver Rule

Rachel Maddow, in a discussion related to the provision of abortion services, once proposed that we (society) should invoke the Amish Bus Driver Rule whenever medical professionals invoke their personal convictions in refusing to provide legal medical services.

The Amish Bus Driver Rule goes like this: If you’re Amish, and therefore have religious convictions against internal combustion engines, then you have disqualified yourself for employment as a bus driver.  …..

…………………………………….

From twitter:  @SusannahFox

#ACS2010 survey: Half of surgeons use FB; 20% use Twitter http://bit.ly/9XRBFt (PDF via @Sani2012)

Compare to @Pew_Internet survey: Half of all adults use FB, MySpace, LinkedIn; ~13% use Twitter http://pewrsr.ch/awb5wt

The first tweet links to this article: Time to Tweet: Session highlights importance of social networking for surgeons (page 1 and 3 of the PDF file)

………….According to Dr. Glick, 7% of the U.S. population is on Twitter, while 20% of ACS survey respondents (approximately 300 as of last week) are on Twitter. 41% of the U.S. population is on Facebook, compared with 64% of ACS survey respondents (see table, page 3). The more sobering results, according to Dr. Glick, are the number of ACS survey respondents who participate in online forums or read online health blogs – 34.5% – which is a comparatively low number.  ….

………………………….

Fellow physician, blogger, and twitterer  Jill of All Trades, MD has begun doing a podcast!  The podcast, Girlfriend M.D.,  is part of Quick and Dirty Tips family. She will be sharing the hosting duties:

Join Dr. Sanaz Majd and guest host Dr. Lissa Rankin as they answer the most common questions women have about their bodies and their health. This is a chance for you to learn about all those issues you were so curious about, but were too afraid or embarrassed to ask about. Girlfriend MD will show you that you are not alone, and that no topic is off-limits. After all, we are all girlfriends here.

…………………………..

From the #hcsm twitter chat this past Sunday evening – a very helpful tip sheet to use in searching for health information online:

@pfanderson T2 My tip sheet for patients using ehealth info w/docs http://www-personal.umich.edu/~pfa/mlaguide/free/quickgd.pdf #hcsm

It is a pdf file, but I encourage you to check it out. 

………………………………….

Dr Anonymous’ show will be about  DigPharm Mtg. The show begins at 9 pm EST.

Upcoming shows:

10/23 : Saturday Nite
10/28 : About FMEC Mtg
10/30 : On Location

You may want to listen to the shows in his Archives. Here are some to get you started:

GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

Monday, October 18, 2010

Lovenox Instructions

I have been using Lovenox more often so I decided to create a patient instruction sheet.  Feel free to use it for your patient (changing the contact information) or give me feedback to make it better for my patients. 

I plan to circle the dose and risk option for each patient and write in the days to be continued.   At the bottom of my page, I added a footer with two emails:  _____@medscape.com  (HIPPA secure, not pushed to iPhone) and ____@gmail.com (non-HIPPA secure, pushed to iPhone)

 

Lovenox Instructions

40 mg SC once daily / 30 mg SC once daily (try to give the same time each day)

Begin: 2 hours prior to surgery

Continue: __________ (7 to 10 days)

The package that comes with Lovenox should have good instructions on how to administer the subcutaneous (SC) injection, but if you need more information (ie video) you can find it here:
http://www.lovenox.com/hcp/dosing/lovenox-administration.aspx

 

You are welcome to bring your used sharps (the needles and syringes) to me for disposal.  Or for more  information on Sharps Medical Waste Disposal check out this site: http://www.uscsr.sanofi-aventis.us/Patient/disposal-of-Medical-Waste.aspx

 

The use of Lovenox is only part of the prevention of deep venous thrombosis.  During surgery you will have intermittent pneumatic compression devices placed on your legs.  After surgery you need to avoid dehydration and do the following:

    *Low Risk (less than 2 %)
      Ambulate three times daily for 5 minutes minimum each time
      Flex and extend ankles often

    *Moderate Risk (10-20%)
      1. Ambulate as above
      2. Flex and extend ankles often
      3. TED stockings

    *High Risk (20-40%)
      1. Same as moderate (1-3)
      2. Lovenox (enoxaparin sodium) SQ for 7-14 days

    *Highest Risk (40-80%)
      1. Same as high risk
      2. Lovenox, Fondaparinux SQ, Heparin or Warfarin (depends on procedure & patient history)

Remember the use of Lovenox increases your risk of bleeding and bruising, but this is easier to deal with and less life threatening than the complications due to deep venous thrombosis. 

You are welcome to email me for non-emergency concerns.  Please allow 24-48 hrs for the email to be answered.  If you need an answer sooner then call the office (******) or have me paged (*******).   

Sunday, October 17, 2010

Razorback Surgeon's Caps for a Colleague

The fall issue of Arkansas (Vol 60, No 1), the Arkansas Alumni Association magazine, included a letter from a fellow UA and UAMS alum – Phillip B. Hurley, MD.  He was a year ahead of me at both schools.  He was a fellow physics major.  He is now an orthopedic surgeon in Kentucky.

His letter noted that he had been part of a medical group (Global Outreach International) who went to Haiti shortly after the earthquake.  It included this photo of him wearing Razorback scrubs. 

I felt he needed a matching surgeon’s cap rather than the disposable blue bouffant cap.  It took me a while to find some Razorback fabric as the stores here were all sold out.   I did though and here they are.  I hope he likes them.

Here is photo of me trying it on and you can see why I stick to the disposable caps.  My hair which I am growing back out isn’t easily contained.

Friday, October 15, 2010

Blog Action Day 2010

This years topic for Blog Action Day is water.  Many of us take clean water for granted, but even in the United States we are finding more and more that our drinking water is contaminated with prescription drugs.  Dry years put our water reservoirs at risk and often result in mandatory restrictions on water use.

I am guilty of taking water for granted.  I do try to use a full load when washing my clothes.  I do turn off the water while brushing my teeth.  I don’t water my lawn regularly.

But I am still guilt of taking it for granted.  I expect clean water to be there for me to drink and use for bathing.

Clean water is not the norm for many in the world.  Nearly one billion people lack basic access to safe drinking water.  That’s nearly 1 out of every 8 of us. 

Organizations like CharityWater.org are trying to bring clean wells to areas in Africa that lack clean water.

water as a catalyst: disease prevention.
charity: water focuses on life’s most basic need -- water. But to significantly cut down disease rates in the developing world, water is just the first step. Almost everywhere charity: water builds a freshwater well, we also require sanitation training. In some communities, we build latrines; at the very least, we promote simple hand-washing stations made with readily-available materials. Clean water can greatly alleviate the world’s disease burden, but only with education and hygienic practice. charity: water is committed to using water as a gateway to sanitary living.

Access to clean water would help eliminate the nearly 38,000 deaths of children under the age of 5 who die weekly from unsafe drinking water and unhygienic living conditions.

Learn more. Perhaps donate to one of the charities like CharityWater.orgSign the petition for an International Water Treaty to Provide Clean Water Everywhere.

 

Earlier this year I made some quilt blocks for Global Quilt Project who is making a quilt that will be auctioned off and 100% of the proceeds will go to a new well for a village in Central African Republic and a latrine for a school in CAR.

      Pink Bandanna Quilt

      I made this quilt for my sister Cathy using bandana’s given out at the Susan G. Komen Race for a Cure here in Little Rock, AR (though I don’t recall which year). The bandana’s were a “freebie” from Ford. This year’s race takes place tomorrow. I'll be walking the 5K with @gastromom and @potato_chip.

      The quilt is machine pieced by me and hand quilted by Scottie Brookes. I then did the binding, finishing the quilt in July 2004. The quilt measures 75 in X 89 in.

      Here is a close up to show the fabrics better.

      Thursday, October 14, 2010

      Foreign Bodies in the Skin

      I recently read a nice review article on the topic:  Diagnosis and Management of Foreign Bodies in the Skin.   Most humans at one time or another will have an experience with a foreign body – splinters, thorns, broken glass, etc.

      Physicians see the worst ones.  The ones that aren’t easily removed or only partially removed.

      The history of the injury is always the starting place.   It is important to know when (recent, days or weeks ago), where (home, farmyard, ocean, etc), how (sharp object, fist to mouth, blunt object), and if known the possible foreign body (splinter, fish spine, teeth, glass).

      Remember fragments of the foreign body can be left in the wound even if you or the patient think it was removed.  Check to make sure the “needle” is complete, etc.

      It is also important to remember with blunt penetration other materials may be embedded along with the offending agent.

      If a nail penetrates both the shoe and the sock, it may also force leather, rubber, or sock material into the foot. A blunt object may push a plug of epidermis deep into the dermis. This traumatic implantation results in an epidermal inclusion cyst.

      When assessing the patient remember 4 P's: pain, pulselessness, paresthesia, and pallor.

      Pain to palpation over an embedded foreign body can help you locate it, especially when located under the skin but above the muscle layer as is the focus of this article.

      Pulselessness and pallor can indicate a vascular injury.  Paresthesia can indicate a nerve injury.

      The article has a nice section on radiologic evaluation of foreign bodies under the skin which can be very important in localization of the object.  Especially important when it’s an old injury with healed skin (visualization impossible), infected wound (patient won’t allow adequate palpation exam), foreign body deeper than 5 mm, etc.

      Diagnostic tests used to determine the location of a foreign body in the skin, include x-ray, computed tomography (CT) scan, ultrasonography, and magnetic resonance imaging (MRI).

      X-ray -- A plain film should be ordered first if a suspected foreign body is not visible to the eye during the initial exam.

      Metal, aluminum, bone, some types of fish spines, teeth, graphite (from pencils), some types of plastics, glass, gravel, stone, wood, and sand are visible on plain x-ray.

      Multiple projections can also be used to help estimate the location of the foreign body after placement of radiopaque skin markers, such as paper clips, on the skin at the wound site.

      CT Scan may be more sensitive than plain-film x-ray, but they also cost more and have an increased radiation dose. 

      Ultrasonography  is a great tool to use to locate foreign bodies made of wood, plastic, and radiolucent materials that are larger than 4 to 5 mm.

      Ultrasonography has a sensitivity of 50% to 90% and may be used to estimate the depth and size of a foreign body, as well as determine its relationship to surrounding anatomic structures.

      Magnetic Resonance Imaging  should not be used on foreign bodies suspected to be gravel or metal-containing.  As with CT scans, this choice can be more expensive and has a higher radiation dose than plain x-rays.

      One of, if not the most important thing, to remember in removing foreign bodies is to inspect the removed object and try to assess whether is has been removed entirely rather than leaving part of it.

      Otherwise, it’s good basic wound care – clean, irrigate, closure, tetanus status, antibiotics or not, etc.

       

       

       

      REFERENCES

      Diagnosis and Management of Foreign Bodies in the Skin; Winland-Brown, Jill E., Allen, Sandra; Advances in Skin & Wound Care. 23(10):471-476, October 2010; doi:  10.1097/01.ASW.0000383220.72147.e2

      Wednesday, October 13, 2010

      Pyoderma Gangrenosum of the Breast

      I was prompted to delve into this topic not because I had a patient with the problem, but because of a MDLink to an article (the first one listed below, subscription required). 

      The eMedicine article states:

      Pyoderma gangrenosum (PG) is an uncommon ulcerative cutaneous condition of uncertain etiology. Pyoderma gangrenosum was first described in 1930. It is associated with systemic diseases in at least 50% of patients who are affected. The diagnosis is made by excluding other causes of similar appearing cutaneous ulcerations, including infection, malignancy, vasculitis, collagen vascular diseases, diabetes, and trauma. Ulcerations of pyoderma gangrenosum may occur after trauma or injury to the skin in 30% of patients; this process is termed pathergy.

      The 2 primary variants of pyoderma gangrenosum are the classic ulcerative form, usually observed on the legs, and a more superficial variant known as atypical pyoderma gangrenosum that tends to occur on the hands.

      Pyoderma gangrenosum (PG) is not common.   It occurs in about 1 person per 100,000 people each year in the United States.   Basically, PG is a noninfectious neutrophilic dermatosis.

      Patients with PG may have involvement of other organ system, most commonly the heart, the central nervous system, the GI tract, the eyes, the liver, the spleen, bones, and lymph nodes.

      It is characterized by the presence of 1 or more ulcerations that are typically violaceous with an undermined border. Diagnosis is clinical and dependent on the exclusion of other causes of cutaneous ulceration. No specific pathologic or laboratory findings exist. Concurrent systemic disease occurs in 50% of affected patients. Commonly associated conditions include inflammatory bowel disease, arthritis, and hematologic malignancy. The remaining cases are considered autoimmune or idiopathic

      The 5th reference article is open access.   The article is a case presentation of PG localized on the breast (photo credit) in a 51-year-old woman who presented with a large, moderately painful ulceration on her right breast which began 12 days prior to presentation with no history of  injury or trauma. 

      Along with the case presentation, the authors notes that in a literature review only 31 cases of PG had been reported (article published in (January 2010).

      In most of these cases the lesions were related to previous surgical interventions, probably as the result of a pathergy phenomenon. The main differential diagnoses were skin and soft tissue infections including necrotizing fasciitis, and malignant neoplasms. Negative initial wound cultures and the relative sparing of nipple/areola complex helped to eliminate these disorders.

      PG doesn’t respond to antibiotic therapy or the usual wound care.  This is a often the first tipoff.  The recommended therapy involves steroids not antibiotics.

      Topical therapies include gentle local wound care and dressings, superpotent topical corticosteroids, cromolyn sodium 2% solution, nitrogen mustard, and 5-aminosalicylic acid. The new topical immune modifiers tacrolimus and pimecrolimus may have some benefit in certain patients.

      Systemic therapies include corticosteroids, cyclosporine,  mycophenolate mofetil, azathioprine,  dapsone, tacrolimus, cyclophosphamide, chlorambucil, thalidomide, tumor necrosis factor-alpha (TNF-alpha) inhibitors, and nicotine.

      Intravenous therapies include pulsed methylprednisolone, pulsed cyclophosphamide, infliximab,  and intravenous immune globulin.

      Other therapy includes hyperbaric oxygen.

      Surgery should be avoided, if possible, because of the pathergic phenomenon that may occur with surgical manipulation or grafting, resulting in wound enlargement. In some patients, grafting has resulted in the development of pyoderma gangrenosum at the harvest site. In the cases in which surgery is required, the best plan, if possible, is to have the patient on therapy in order to prevent pathergy.

       

       

       

      REFERENCES

      1.  Pyoderma gangrenosum of the breast: A diagnosis not to be missed; A. Duval, N. Boissel, J.M. Servant, C. Santini, A. Petit, M.D. Vignon-Pennamen; Journal of Plastic, Reconstructive & Aesthetic Surgery - 20 September 2010 (10.1016/j.bjps.2010.07.022)

      2.  Pyoderma Gangrenosum; eMedicine article, March 23, 2010; J Mark Jackson, MD, Jeffrey P Callen, MD

      3.  Pyoderma gangrenosum; Orphanet Encyclopedia, September 2003; Wollina U.

      4.  Atypical Pyoderma Gangrenosum After Breast Reduction;  Karoly Gulyas, FrankW. Kimble; Aesthetic Plastic Surgery Vol 27, No 4, 328-331, DOI: 10.1007/s00266-003-3017-y

      5.  Pyoderma gangrenosum on the breast: A case presentation and review of the published work; Ayşe Tülin Mansur, Deniz Balaban,  Fatih GÖKTAY, Sezen Takmaz, The Journal of Dermatology, Special Issue: Systemic Sclerosis (pages 1-84) Volume 37, Issue 1, pages 107–110, January 2010; DOI: 10.1111/j.1346-8138.2009.00756.x

      Tuesday, October 12, 2010

      Shout Outs

      e-Patients is the host for this week’s Grand Rounds! You can read this week’s edition here.

      This is e-Patients.net’s first opportunity to host Grand Rounds. which is a collection of some of the medical blogosphere’s best writing over the last week. We asked bloggers to look at our sister website, the peer-reviewed Journal of Participatory Medicine, and create posts inspired by or extending the articles there. We did this not to be self-serving, but because we think it’s important to shine a light on the Journal’s role as a source of peer-reviewed, evidence-based participatory medicine research. A group of us formed the Society of Participatory Medicine to advance the credibility and understanding of patient empowerment and patient advocacy.

      We want to dedicate this edition of Grand Rounds to our friend and mentor, Dr. Tom Ferguson, founder of e-Patients.net and direct inspiration for the founding of the Society for Participatory Medicine and the Journal of Participatory Medicine. Tom’s selfless, tireless work in support of the empowered patient culminated in the creation of the seminal, visionary white paper, e-Patients: How They Can Help Us Heal Healthcare (pdf), published just after his death.

      Thanks also to Nick Genes and Val Jones, instigators of Grand Rounds.

      This week’s posts …

      ……………………………………….

      Slate has a thoughtful article by Elaine Schattner: Who's a Survivor? An oncologist who's had breast cancer considers the problematic phrase "cancer survivor."

      A few weeks ago, I stood among 21,000 people at the Susan G. Komen Foundation's annual Race for the Cure in New York City. The participants, including me and 1,500 other breast-cancer survivors, walked, ran, or wheeled their way to the finish line in Central Park. Nearby was a "survivors' village." I wandered about, uncertain whether I belonged.

      Survivor seems a strange term for a patient like me, said by her oncologist to be in remission—meaning that there's no overt evidence of persistent cancer cells in the body. The National Cancer Institute defines a "cancer survivor" as someone who's had a malignant tumor and remains alive. …..

      …………………………………….

      Literature, Arts, and Medicine Blog has a post on October 6, 2010:  Medical Humanities and Live Theater. See It Now! (the post’s link seems to be broken, so it’s a link to the blog itself)

      For those living in or near New York City, there is an unusual opportunity to attend one or all of three plays that bear directly on individual experiences of illness, altered bodily states, and the cultural and social context in which those alterations occur. …

      Angels in America, by Tony Kushner. Signature Theater Company."This play explores "the state of the nation"-the sexual, racial, religious, political and social issues confronting the country during the Reagan years, as the AIDS epidemic spreads. ….

      Three Women, by Sylvia Plath. 59E59.
      "three intertwining interior monologues, contextualized by a dramatic setting: " ‘A Maternity Ward and round about.’ . . The three women of the title are patients, and each describes a different experience."

      Wings, by Arthur Kopit. Second Stage Theater.
      "the sounds and sights inside and outside of Emily as well as her private dialogue are combined masterfully by Kopit to bring about a high degree of verisimilitude to the chaos produced by stroke."

      ……………………………….

      Fellow physician, blogger, twitterer, and "angel" Dr. Krupali Tejura's recent presentation: How the real-time web is changing the lives of my cancer patients

      …………………………..

      I learned of this blog, Never Lose Spirit,  by a local breast cancer patient via our local newspaper.  I love her header (photo credit).  She is the mother of two daughters.

      Welcome to my blog. I've created this blog to keep friends and faraway family up to date on my battle with Inflammatory Breast Cancer. When you’re a writer, there is no need to be reported about - right? So instead, I’m going to be the author of my own story. You keep praying while I fight this nasty disease. We’re going to win!

      ………………………………….

      Dr Anonymous’ show will be about Social Health Track at BlogWorld Expo. The show begins at 9 pm EST.

      Upcoming shows:

      10/16 : On Location
      10/21 : About DigPharm Mtg
      10/23 : Saturday Nite
      10/28 : About FMEC Mtg
      10/30 : On Location

      You may want to listen to the shows in his Archives. Here are some to get you started:

      GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

      Monday, October 11, 2010

      Safe Pumpkin Carving

      It’s that time of year again!  Carving pumpkins for jack o’lanterns can be fun, but if safety isn’t kept in mind can also result in cut fingers.

      Minor cuts will often stop bleeding on their own or by applying direct pressure to the wound. Most of these cuts and scraps will be minor and can be treated by washing with soap and water initially. After this initial care, keep the wound clean and dry while it heals.

      However, if the bleeding continues after 15 minutes or if you lose the ability to move the finger properly (very likely a tendon injury), then seek medical attention at a hospital emergency department.

      Rather than treating injuries, let's prevent the injuries.

      It is best to keep these tips in mind:

      • Carve in a clean, dry, well-lit area.   If your tools, hands or cutting table are wet, this can cause slippage and lead to injuries.

      • Always have adult supervision (without alcohol use).  Children under age five should never carve. Instead, allow kids to draw a pattern or face on the pumpkin and have an adult carve. Allow the child to be responsible for cleaning out the inside pulp and seeds. They can use their hands or a spoon for this. Children, ages five to ten, can carve but only with adult supervision.

      • The right way to cut.   You should always cut away from yourself in small, controlled strokes. A sharp knife is not necessarily the best tool because it often becomes wedged in the thicker part of the pumpkin, requiring force to remove it. An injury can occur if your hand is placed incorrectly when the knife dislodges from the thicker part or slips.

      • Use a pumpkin carving kit.
        Special pumpkin carving kits are available for purchase and  include small serrated saws that are less likely to get stuck in the thick pumpkin. If the saw does get stuck and then becomes free, it is not sharp enough to cause a major cut. Fewer injuries occur with use of carving kits.

      Here’s my finished carving

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

      Have a safe Halloween season!

      Friday, October 8, 2010

      Rushed Roses Quilt -- Work in Progress

      One of my very early post on this blog featured the rushed roses on this quilt. The post is dated May 22, 2007. Yes, that means I have allowed this quilt top to languish for over three years. I admit I fell “out of love” with the quilt top. I love the rushed roses and center, but the blue border doesn’t work for me.

      The need to appliqué all the small leaves slowed me down too. I admit it was easier to put it aside and piece a baby quilt or two instead.
      The quilt top has literally hung on my design wall all this time. Granted often covered up by some other work-in-progress. I have decided it is time to re-design the border and breathe new life into the project.

      I pulled out my books looking for inspiration. I found a pieced border I felt would work. It is the "double folded ribbon" pattern from Jenny Beyer's book: The Quilter's Album of Blocks & Borders which she credits to Nancy Nelson, 1979.
      I like it much better. I have now removed the blue border and replaced it with the pieced one. I have machine appliqued the leaves in place.

      Now I am trying to decide how I want to quilt it. This will also determine whether I need more roses/leaves in the corners.  While I decide I’m also working on more baby quilts.

      The instructions for making a ruched rose can be found in American's Heritage Quilts published by Better Homes and Gardens, 1991.

      Thursday, October 7, 2010

      Stem Cell Face-Lifts?

      It’s been almost a month since the LA Times ran the article by Chris Woolston:  The Healthy Skeptic: Stem cell face-lifts on unproven ground.  It’s well written and presents a fairly balanced view.  While I am a fan of stem cell research, I think the “claims” are often put ahead of the science.  This is one of those times.  I can’t find any decent articles to support the claims of the plastic surgeons doing “stem cell face-lifts.”

      My view is echoed in the article (bold emphasis is mine):

      Rubin says he's excited about the potential of stem cells in the cosmetic field and beyond. Still, he adds, there are many unanswered questions about the cosmetic use of stem cells, and anyone who claims to have already mastered the technique is jumping the gun. As Rubin puts it, "Claims are being made that are not supported by the evidence."

      While researchers in Asia, Italy, Israel and elsewhere are reporting decent cosmetic results with injections of stem cell-enriched fat, Rubin says that nobody really knows how the stem cells themselves are behaving. He points out that fat injections alone can improve a person's appearance, no stem cells needed.

      Rubin believes it's possible that injected stem cells could create new collagen and blood vessels — as they have been shown to do in animals studies — but such results have never been proved in humans. And, he adds, the long-term effects of the procedures are an open question.

      Stem cell face-lifts could someday offer real advances, says Dr. Michael McGuire, president of the American Society of Plastic Surgeons and a clinical associate professor of surgery at UCLA. But he believes that scientists are still at least 10 years away from reliably harnessing stem cells to create new collagen and younger-looking skin. Until then, promises of a quick stem cell face-lift are a "scam," he says.

      The American Society for Aesthetic Plastic Surgery (ASAPS) issued a statement two weeks after the article first appeared --Stem cell therapy 'could offer women natural breast enhancement from stomach fat'

      “Procedures with no solid science behind them, stem cells included, give unproven hope to patients and the marketing of them brings dishonor to our entire specialty,” said Felmont Eaves, III, MD of Charlotte, NC, President of ASAPS.  The Aesthetic Society is working together with the other core societies to address this through an evidence based medicine program that will rate any procedure or device on the legitimacy of the scientific evidence behind it.  This program is in its development stage and will be available to the public within the next 12 months”.

      “The use of ‘stem cells’ in advertising for cosmetic surgical applications is a global problem," says Doug Sipp, Head of the Science Policy and Ethics Study Unit at the Center for Developmental Biology of RIKEN in Kobe, Japan, who monitors supposed stem cell treatment claims worldwide in all different specialties.  "There have been many cosmetics, nutraceuticals, and device makers who claim either to use stem cells in their products, or to use ingredients that activate the customer’s own stem cells. To the best of my knowledge, none of these has a basis in scientific evidence."

      Marketing.  That seems to be the issue here.  And there is much money to be made in promises that may or may not be kept with the use of stem cells.  From the LA Times article:

      Stem cell face-lifts: A Sept. 13 Health section story assessing stem cell face-lifts offered by two Beverly Hills doctors said that Dr. Nathan Newman charges between $5,500 and $9,500 for the procedure and Dr. Richard Ellenbogen charges $15,000 to $25,000. The story should have noted that Ellenbogen often performs a surgical face-lift along with his injection of stem cells. —

      Wednesday, October 6, 2010

      Liposuction Overview

      I use the form of liposuction commonly called traditional though it is more accurately called superwet suction-assisted liposuction (SAL).   Why don’t I use ultrasound or laser assisted?  Cost mainly.  I find it difficult to purchase all the latest and greatest equipment.  I find it difficult to ask the hospitals/surgery centers I work at to do the same when I’m not sure I can guarantee them patients numbers needed to recoup the costs.

      Superwet SAL has worked well for me and my patients.  I have found that the greatest improvements to liposuction since it’s introduction by Illouz in the 1980s have been the addition of the wetting technique and the improvement in cannula size (specifically much smaller ones available than the early years).

      I have been trained to use ultrasonic liposuction and have used it, but without renting equipment it is not available routinely at all the facilities I work.  SAL is.

      I wanted to state all the above before delving into the article “Updates and Advances in Liposuction” (full reference below) as a way of full disclosure.  The article is a very nice review of liposuction.

      The authors point out the key elements to not just achieving a good result but to maintaining it.  Points which should be made to each patient: 

      A successful body contouring patient must satisfy four key elements to achieve and maintain optimal results.
      1. Lifestyle change
      2. Regular exercise
      3. Well-balanced diet
      4. Body contouring

      Notice the surgeon is only important in the last one.  The individual is the key in long-term satisfaction with liposuction.

      In discussing the addition of wetting solutions (often lumped together incorrectly and simple called tumescent), the authors point out that initially when liposuction was done without any wetting solutions the blood loss was often up to 45% of the aspirate.  The addition of a wetting solution greatly reduces the amount of blood lost.

      All of the formulations of wetting solution include some variant of fluid (NS/LR), epinephrine, and lidocaine.   Wetting solutions are used in three techniques:  wet, superwet, and tumescent.

      The wet technique involves instillation of 200 to 300 mL of solution per area to be treated, regardless of the amount aspirated.

      The superwet technique employs an infiltration of 1 mL per estimated mL of expected aspirate, and this is the technique practiced at our institution. 

      Tumescent infiltration, popularized by Klein, involves infiltration of wetting solution that creates significant tissue turgor and results in infiltration of 3 to 4 mL of wetting solution per mL aspirated. 

      Recent data suggest that, for patients undergoing general anesthesia with the superwet technique, the lidocaine component may be reduced and/or eliminated without postoperative sequela of increased pain.

      I tend to use only epinephrine and not any lidocaine in my wetting solution.  I have a (healthy?) fear of lidocaine toxicity and since my liposuction patients have general anesthesia decided years ago there was no need for the added lidocaine.

       

      Traditional liposuction is referred to as suction- assisted liposuction (SAL).  Other liposuction modalities include ultrasound-assisted liposuction (UAL), vaser-assisted liposuction (VAL), power-assisted liposuction (PAL), and laser-assisted liposuction (LAL).

      SAL remains the most common modality for liposuction. As mentioned above, it is the one I use.  SAL uses variable-size cannulas and an external source of suction for removal of the aspirated fat.

      PAL involves an external power source driving the cannula.  Advocates of PAL contend that it is best used for large volumes, fibrous areas, and revision liposuction.

      UAL utilizes ultrasound energy to break down fat and allow removal.  With this technique, fat is emulsified, which allows removal through traditional liposuction cannulas.  This modality requires a superwet environment.

      Advantages include less surgeon fatigue, as well as improved results in fibrous areas and in secondary procedures. 

      Disadvantages have been reported to include larger incisions, longer operative times, and the possibility of thermal injury.  

      VAL uses a newer generation ultrasound-assisted liposuction device.  The system uses less energy, decreasing its thermal component to the tissues.  VAL  may be better than the other modalities in large-volume liposuction as it has less blood loss. 

      This is what the article has to say regarding LAL (bold emphasis is mine):

      LAL has been at the forefront of marketing hype for the past several years. The treatment involves insertion of a laser fiber via a small skin incision. Depending on the manufacturer, the fiber may either be housed within a cannula or stand alone. ….  Most companies and physicians utilizing this technique employ a four-stage technique: infiltration, application of energy to the subcutaneous tissues, evacuation, and subdermal skin stimulation.  …… Currently, these devices are being heavily marketed for purported skin-tightening effects. The belief is that the heating of the subdermal tissue may in fact be the contributing factor for LAL’s possible skin tightening effect.  No large, prospective trials have been undertaken to examine the benefits of LAL over existing technologies, so unfortunately, most of the reports remain anecdotal. 

       

      Liposuction is a shaping technique, not a weight-loss solution.  Liposuction will also not treat cellulite and can in fact make it appear worse.

      Risks should be discussed with patients as with they are with all surgical procedure.  The risks common to all modalities of liposuction include contour deformity, ecchymosis, edema, seroma, infection, paresthesia/dysesthesia, anesthesia and cardiac complications, cannula trauma to skin and/or internal organs, volume loss/overload from bleeding or excess fluid administration, hypothermia, deep venous thrombosis (DVT)/ pulmonary embolism (PE), and death.  

      In a questionnaire to board-certified members of ASAPS, Hughes reported a significant increase in complications when liposuction was combined with other procedures. This increase in the complication rate was most notable in liposuction combined with abdominoplasty. …….

      Incidence of DVT in liposuction has been reported at <1%, but a marked increase in this percentage is demonstrated when liposuction is combined with other surgery (abdominoplasty/belt lipectomy).

      Prolonged edema can occur up to three months from surgery and is best treated with supportive care and lymphatic massage.

      Postoperative paresthesia/dysesthesia can occur in all forms of liposuction, is usually reversible, but may take up to 10 weeks to recover.  Improvement of paresthesia/dyesthesia issues are generally felt to be quicker with SAL than with UAL.  The newer technologies have not been investigated in this manner.

      The most common postoperative complication from liposuction is contour deformity, which can occur in up to 20% of patients.

       

       

      REFERENCES

      Stephan, Phillip J., Kenkel, Jeffrey M.; Updates and Advances in LiposuctionAesthetic Surgery Journal January 2010 , 30: 1: 83-97, doi:10.1177/1090820X10362728