Management of Latex Allergic Surgical Patient

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

A couple of nice articles recently on latex allergy have crossed my path – one in a journal I subscribe to (Aesthetic Surgery Journal) and the other via twitter and @Allergy  (Ves Dimov, M.D., blogs at Allergy Notes).  I’ve put both full references below.

Latex allergy became widely recognized in the late 1980s and early 1990s.  The increase in latex allergies cases is felt to be associated with the increase use of latex gloves and implementation of universal precautions (now known as standard precautions) in the 1980s.

Management of possible or confirmed latex allergic patients begin with history and suspicion:

All patients who present for surgical procedures or exams which require latex gloves (pelvic exam, dental exams, etc) should be questioned about possible latex allergy.

Patients at highest risk include those who have a history of multiple surgeries (especially for urogenital abnormalities which may require frequent urinary catheterizations), allergic disease, or spina bifida, or who are employed in occupations with inherent latex use (ie, healthcare workers).

If an individual patient notes a history of food allergies (atopy), pay special attention if those foods include banana, kiwi, avocado, or stone fruits like cherries or peaches which are associated with latex allergy.

Regardless of the cause, the presence of hand dermatitis is a risk factor for developing latex allergy among healthcare workers

Confirmation of latex allergy is achieved through laboratory testing.  Dr. Dimov has a nice post which explains this:  Latex Allergy - ACAAI Video

Confirmation should be done if there is time.  If not, then proceed as if the patient is latex allergic.

Here’s my check list:

1.  When I schedule the procedure, I inform the facility so they can prepare using their own check list (ie special cleaning of room and anesthesia equipment, pulling of latex free supplies, labeling room as latex-free, etc).

2.  I schedule latex-sensitive/allergic patients as the first case of the day.  This assumes it is an elective case and not an emergency.

3.  If I need girdles or other postoperative garments, I make sure they are latex-free when I order them.

……

The second article (the one from Dr. Dimov) takes a look at hospital policies which ban the use of natural rubber latex (NRL) devices and whether they may be an overreaction.

Their conclusions (bold emphasis is mine):

With the reduced incidence of allergic reactions, the availability of specific and sensitive testing for the selection of low-allergen gloves, competitive costs and lower environmental impact, NRL remains an excellent choice of material for medical gloves and should continue to be used.

In recent years, a number of high profile institutions have moved to a totally NRL-free environment, including gloves. However, the evidence within Europe demonstrates that the many benefits of NRL can be retained by purchasing low-allergen, low-protein and powder-free gloves, thereby reducing the risk of type I and type IV sensitization as well as allergic reactions.

NRL gloves are characterized by a high level of barrier performance for staff and patients, good comfort allowing staff to perform safely and efficiently, and competitive pricing in a period of economic difficulty. NRL is an environmentally sustainable material, which is also naturally biodegradable, enabling hospitals to meet their ‘green’ purchasing requirements.

Finally, compared with various synthetic materials, NRL is generally better accepted by the clinicians. There will, of course, be a continuing requirement for synthetic gloves for known latex-allergic patients and staff, and for these purposes several options are currently available. In conclusion, we believe that a sensible balance requires a mix of latex and synthetic gloves.

 

REFERENCES
Recognition and Management of the Latex-Allergic Patient in the Ambulatory Plastic Surgical Suite;  Deborah Accetta and Kevin J. Kelly; Aesthetic Surgery Journal July 2011 31: 560-565, first published on June 1, 2011 doi:10.1177/1090820X11411580
Latex Medical Gloves: Time for a Reappraisal; Palosuo T, Antoniadou I, Gottrup F, Phillips P; Int Arch Allergy Immunol 2011;156:234-246 (DOI: 10.1159/000323892)

Nutrition and Wound Healing

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

Nutrition, or rather the new USDA Dietary Guidelines, have been in the news this week.  It seem apropos to take not of a recent article in the supplement to the January issue of the Plastic and Reconstructive Surgery Journal discussing nutrition and wound healing (full reference below).

The article presents an update on new developments in the field of nutrition and wound healing, not an exhaustive review of the field.

As the authors point out “most operations in well-nourished patients are successful, with uncomplicated healing responses, even if nutritional intake is absent or curtailed for 7 to 10 days.”   It’s the patient with trauma, cancer, chronic illnesses, mal-absorption issues where this is most important.

First and foremost, the nutritional assessment should begin with a complete history and physical.  The authors reference the second article below for this statistic:

This alone has been found to be 80 to 90 percent accurate in evaluating patient nutritional status, and the addition of multiple or complex biochemical, immune, or anthropometric measurements does not increase greatly the accuracy of nutritional assessment.

Malnutrition should be considered if the history reveals unintentional weight loss (20% weight loss is indicative of severe malnutrition), if the patient appears cachectic with obvious muscle wasting, or if the patient has a history of or reason for alimentary malabsorption.  It must also be remembered that Obese Patients are at High Risk for Malnutrition in the Hospitalized Setting.

If the patient is found to be malnourished prior to an elective surgery, this should be corrected.  As the authors point out:

Determining who would truly benefit from nutritional supplementation is still a matter of some debate, but there is evidence that preoperative nutritional support reduces infectious complications and anastomotic breakdown in severely malnourished patients undergoing major elective surgery.

Postoperative nutritional support should be considered in patients expected to be unable to eat for a period of at least 2 weeks.

Other key points from the article:

• Enteral feeding is superior to parenteral feeding when possible.
• Fish oil supplements (omega-3 fatty acids) adversely impacts the healing response.
• Vitamin C deficiency, in addition to impairing wound healing, has also been associated with an increased susceptibility to wound infection.  Burn victims require as much as 1 to 2 g/day to restore urine and tissue levels to normal.
• Vitamin A deficiency impairs wound healing.  Vitamin A, administered either topically or systemically, reverses the antiinflammatory effects of corticosteroids on wound healing.
• The antiinflammatory properties of vitamin E are similar to those of steroids. Vitamin A can reverse the wound-healing impairment induced by vitamin E. Vitamin E has also been shown to affect various host immune functions, often in a negative fashion.
• Zinc deficiency impairs the critical roles each of these processes play in wound healing. Zinc levels less than 100 μg/dl have been associated with decreased fibroblast proliferation and collagen synthesis.

 

Related posts:
Nutritional Deficiency of Post-Bariatric Surgery Body Contouring Patients: What Every Plastic Surgeon Should Know -- An Article Review (September 3, 2008)
Herbal Supplements and Surgery Reviewed (April 30, 2009)
Local Wound Care for Malignant and Palliative Wounds – an Article Review (September 13, 2010)



REFERENCE

Nutrition and Wound Healing: An Update; Kavalukas, Sandra L.; Barbul, Adrian; Plastic & Reconstructive Surgery. 127():38S-43S, January 2011; doi: 10.1097/PRS.0b013e318201256c

Assessment of nutritional status; Jeejeebhoy KN, Detsky AS, Baker JP.;  JPEN J Parenter Enteral Nutr. 1990;14:193S–196S.

Florida Liposuction Death?

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


I was going to wait until the autopsy came back to comment on this news article, but there are points to be made even now.
First, it isn’t known if the death was due to liposuction. 
This December 30th Palm Beach Post article gives the basics and that is all:   South Florida woman, 35, dies getting plastic surgery (bold highlights are mine).

Lidvian Zelaya's New Year's resolution for 2011 was to "look good," so she went to Strax Rejuvenation Center in Lauderhill on Monday to have fat liposuctioned from her waist and added to her buttocks, her husband, Osvaldo Vargas, said.

Three hours later, Vargas said, his wife was rushed to emergency facilities at a nearby medical center. When he arrived there, he was told she had died. She was 35. 

Vargas and his attorney, Spencer Aronfeld of Coral Gables, said they were not sure what doctor performed the procedure nor whether the procedure had started when the medical problems began.

It troubles me that the husband isn’t sure who performed the procedure.  It wasn’t a training hospital, but a private clinic (Strax Rejuvenation Center).  Perhaps it is reports like this one  and this one which has caused a loss of trust in physician integrity.

It troubles me that the husband wasn’t sure the procedure had even started when the medical problems began.  As difficult as it would have been, didn’t Lidvian’s surgeon (reported elsewhere to have seen Dr. Roger L. Gordon in consultation)  sit down and talk with the family?

He may not have done anything wrong.  It may turn out she had an allergic reaction to a medication or malignant hyperthermia or ….

Or perhaps Dr. Gordon did talk to the family, but the grief stricken husband didn’t hear or process it.

This also troubles me, as I know it will Dino Doc who has written on clearing patients for surgery.

From the ABC News article on January 3, 2011:  Did Florida Woman's New Year's Resolution Costs Her Life?  Cosmetic Surgery Gone Wrong Has Family Wondering What Happened 

According to the family, Zelaya was in perfect medical condition, and the clinic cleared her through a pre-operative screening. Now, the family is urging anyone considering cosmetic surgery to undergo a second, pre-surgical health evaluation by an independent primary care physician.

"I think it's an inherent conflict of interest if you are getting screened by the surgeon who wants to do the procedure," said Aronfeld.

Dino Doc that says a lot about why you are increasing asked to do pre-surgery clearances.


Related posts:
Know Your Surgeon (November 3, 2010)
Liposuction – Shaping not Weight-loss  (February 8, 2010)
Liposuction Overview  (October 6, 2010)
Major and Lethal Complications of Liposuction -- An Article Review  (July 16, 2008)

Weight Lifting, Breast Cancer, and Lymphedema

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

Last August, Kathryn Schmitz, PhD, MPH and colleagues published the results of their study Weight Lifting in Women with Breast-Cancer–Related Lymphedema in the New England Journal of Medicine.  They have now published a similar study in the Archives of Internal Medicine (see full reference below).

While the NEJM article focused on breast cancer survivors with lymphedema, the Archives article focuses on breast cancer survivors without lymphedema.

The new study adds weight for the need to change historic dogma which cautions breast cancer patients to avoid weight training after a mastectomy and or axillary dissection.

As noted by Schmitz, etc (bold emphasis is mine):

Breast cancer survivors at risk for lymphedema alter activity, limit activity, or both from fear and uncertainty about their personal risk level, and upon guidance advising them to avoid lifting children, heavy bags, or other objects with the at-risk arm.

Such guidance is often interpreted in a manner that deconditions the arm, increasing the potential for injury, overuse, and, ironically, lymphedema onset.

Adherence to these precautions may limit physical …. Furthermore, activity avoidance may deter survivors from performing regular exercise, which may prevent cancer recurrence and improve survival.

The randomized controlled equivalence trial (Physical Activity and Lymphedema trial) enrolled 154 breast cancer survivors (only 134 completed the study)  1 to 5 years post-unilateral breast cancer with at least 2 lymph nodes removed and without clinical signs of lymphedema.  Recruitment took place between October 1, 2005, and February 2007, with data collection ending in August 2008.

Participants in the weight lifting intervention group (n = 72)received a 1-year membership to a community fitness center near their homes. For the first 13 weeks, women were instructed twice weekly during 90 minute sessions on safe performance of exercises in groups of 2 to 6 survivors.

Upper body exercises (seated row, supine dumbbell press, lateral or front raises, bicep curls, and triceps pushdowns) were performed with dumbbells or variable resistance machines. Lower body exercises (leg press, back extension, leg extension, and leg curl) were performed with variable resistance machines. Three sets of each exercise were performed at each session, 10 repetitions per set.

After 13 weeks, participants continued twice weekly unsupervised exercise to 1 year. Weight was increased for each exercise by the smallest possible increment after 2 sessions of completing 3 sets of 10 repetitions with no change in arm symptoms.

Participants in the control group (n = 75) were asked to not change baseline level of exercise during study participation and were offered a 1-year fitness center membership with 13 weeks of supervised instruction following study completion.

Fewer women experienced incident BCRL onset in the weight lifting intervention group (11%, 8 of 72) compared to the control group (17%, 13 of 75).

The difference was even greater among women with 5 or more lymph nodes removed:  7% (3 of 45) in the weight lifting intervention group and 22% (11 of 49) in the control group.

Once again, this is a small group, but I lean more and more towards allowing motivated patients to begin weight-lifting with a slow, progressive program.   They should learn proper technique.  They should wear their custom-fit compression garment during all exercise sessions.

Weight-lifting has been shown to decrease bone loss which is important in these women as in all women.  Having more strength can also aid in everyday activities like carrying bags of groceries or carrying children/grandchildren.

 

 

REFERENCE

Weight Lifting for Women at Risk for Breast Cancer–Related Lymphedema: A Randomized Trial; Kathryn H. Schmitz, Rehana L. Ahmed, Andrea B. Troxel, Andrea Cheville, Lorita Lewis-Grant, Rebecca Smith, Cathy J. Bryan, Catherine T. Williams-Smith, Jesse Chittams; JAMA. Published online December 8, 2010. doi:10.1001/jama.2010.1837

Weight Lifting in Women with Breast-Cancer–Related Lymphedema; New England Journal Medicine, Vol 361 (7):664-673, August 13, 2009; Kathryn H. Schmitz, Ph.D., M.P.H., Rehana L. Ahmed, M.D., Ph.D., Andrea Troxel, Sc.D., Andrea Cheville, M.D., Rebecca Smith, M.D., Lorita Lewis-Grant, M.P.H., M.S.W., Cathy J. Bryan, M.Ed., Catherine T. Williams-Smith, B.S., and Quincy P. Greene

…….

Related Posts

Lymphedema (December 5, 2007)

ARM Technique (October 15, 2008)

Weight Lifting Good for Breast Cancer Patients  (August 19, 2009)

Drug Abuse in Plastic Surgery Patients

The article (full reference below) is a reminder of drug abuse in our patients.  Many of which can create issue peri-operatively.  The article begins:

In 1957, Dr. George Crikelair detailed the impact of drug abuse on the practice of plastic and reconstructive surgery.   Five decades later, the subject remains salient: surveys administered by the White House Office of National Drug Control Policy (ONDCP) state that 41.7% of the U.S. population older than 12 has taken an illicit drug in their lifetime.  12.6% reported illicit drug use in the past year. 

….. This article seeks to impart clinical savvy regarding verbal and non-verbal cues of the seven most commonly abused drugs by detailing their pharmacology, clinical manifestations, screening and management, thus enabling plastic surgeons to provide prompt and appropriate treatment when encountering complications related to these
drugs.

I would recommend this article be read by more than just plastic surgeons.  It will either educate you or simply be a good review.  I’m not as good at picking drug abuse up as say Gruntdoc or Movin Meat or White Coat, so I found it worth my time.

To begin:

The typical urine drug screen (UDS) is based upon federal guidelines established by the Substance Abuse and Mental health Services Administration, or SAMHSA. This drug screen is referred to as the “SAMHSA-5” (and previously as the “NIDA-5”) because it detects only the five drugs required by federal workplace testing. These include cocaine, opiates, amphetamines, cannabinoids, and phencyclidine (PCP).

Synthetic opioids, such as oxycontin and hydrocodone, will not be noted on these routine screens.

The seven drugs the article reviews are:

Cocaine -- Common names: coke, blow, crack, snow, nose candy

Marijuana  -- Common names: pot, weed, grass, mary jane

Benzodiazepines  -- Common names: benzos, bars, tranks, normies, sleepers and xanies

Opioids  --  Common names: Heroin (H, smack, horse, brown/black tar), Prescription pain medication (oxy, roxy, vike, patches)

Amphetamines -- Common names: speed, uppers, dexies for amphetamine, and meth, crank, crystal, ice for methamphetamine

Gamma hydroxybutyrate --Common names: GHB, liguid Ex, G

Ecstasy  -- Common names: E, Adam, XTC, X, love drug

 

Each drug review includes pharmacology, clinical manifestations, screening, and management sections.   If you don’t have access to the journal, get your medical library to get it for you and READ the article.

 

REFERENCE

Drug Abuse in Plastic Surgery Patients: Optimizing Detection and Minimizing Complications; Cone, J.D., Harrington, M.A., Kelley, S.S., Prince, M.D., Payne, W.G., Smith, D.J.; Plast & Reconstr Surgery: POST ACCEPTANCE, 23 September 2010; doi: 10.1097/PRS.0b013e3181fad5ac

P.O.U.R.

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

A patient with postoperative urinary retention forced me to review the topic, conducting my private M&M conference.

Without giving away too much on my patient – female, less than 50 yo, general anesthesia used, length of surgery 4 hrs, ambulatory/outpatient, foley used intraoperatively, fluids used judicially (though I do not know the exact amount given by anesthesia), pain meds (Toradol, fentanyl, and sent home with script for Percocet).

From the first reference article below

I made my usual call to the patient the evening of surgery, asked how she was, “how’s the pain?”, “any concerns?”, “any nausea?”, “are you eating and drinking?”. I don’t recall specifically asking about whether she had peed or not, but I do recall her saying she needed to end the call so she could go to the bathroom.

I received a call from her the next afternoon. “Dr. Bates, I can’t pee. I keep trying and all I can do is dribble.”

The surgery center graciously agreed to catheterize her. I received a call from them immediately afterwards, “Dr. Bates, her residual volume is 1000+ cc.”

The patient graciously agreed to have the foley left in place for the next 24 hrs. I called her later the same evening and we agreed on a time for her to come into my office for the removal of the foley the next day (and yes, I gave thought into leaving it for a second day).

The surgery center’s action kept my patient from having to check in through the emergency department, incurring a wait time and additional cost.

The patient’s agreement allowed me to treat her as an outpatient, helped me reduce the need for a second catheterization, and keep her from incurring more expense.

It was fortunate that the patient had weaned herself from the pain medicine by this time and was mostly taking only Tylenol. Her P.O.U.R quickly resolved.

I did not see this complication coming for this patient. Perhaps the foley could have been left in and removed in recovery. Perhaps anesthesia could have restricted fluids more (though they were careful).

I can think of no reason she might need a urology follow up. Am I missing anything? Where is KeaGirl when you need her?

REFERENCES

Predictive Factors of Early Postoperative Urinary Retention in the Postanesthesia Care Unit; Anesthesia & Analgesia, August 2005 Vol. 101 No. 2 592-596; doi: 10.1213/​01.ANE.0000159165.90094.40

Postoperative Urinary Retention; Anesthesiology Clinics, Volume 27, Issue 3, Pages 465-484 (September 2009)

Patient Safety in the Office-Based Setting; Horton, J Bauer; Reece, Edward M.; Broughton, George II; Janis, Jeffrey E.; Thornton, James F.; Rohrich, Rod J.; Plastic & Reconstructive Surgery. 117(4):61e-80e, April 1, 2006; doi: 10.1097/01.prs.0000204796.65812.68

Urinary Retention in Adults: Diagnosis and Initial Management; Brian A. Selius, DO, Rajesh Subedi, MD; Am Fam Physician, 2008 Mar 1;77(5):643-650.

Injectables Roundup

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

I have come across some interesting articles recently regarding injectables.  Let’s begin the non-controversial one: Behind the Lines by Linda W. Lewis, Nov/Dec 2010 MedEsthetics (pp 32-.  This one notes several filler discontinuations:

Johnson & Johnson (jnj.com) withdrew porcine collagen-based Evolence in November 2009; Allergan (allergan.com) discontinued its human and bovine collagen fillers, CosmoDerm, CosmoPlast, Zyderm and Zyplast, late last year and will stop distribution by the end of 2010.

The article mentions the latest filler introductions:

Juvederm XC from Allergan and Restylane-L and Perlane-L from Medicis (medicis.com).  These products differ from their predecessors only in the addition of lidocaine to the formulations.

Much greater changes are on the horizon, however, as manufacturers seek approval for exciting new products like Novabel (Merz Aesthetic, merzaesthetics.com) and Aquamid (Contura, aquamid.com).

The article also mentions that some physicians are using Restylane SubQ in buttock and breast enlargements.  This leads me to the next article (full reference below):   Macrolane(TM) for breast enhancement: 12-month follow-up.  The Swedish study used a new formulation of a stabilized hyaluronic acid-based gel of non-animal origin (NASHA(TM)-based gel) called Macrolane(TM) VRF30) in their open-label, multicentre, non-comparative study.

The aim of this study was to develop a reproducible technique for injecting NASHA-based gel posterior to the mammary gland (subglandular injection), and to assess treatment safety and efficacy. The feasibility of dual-plane submuscular injection was also explored.

Twenty-four non-pregnant, non-breastfeeding women (mean age 37 years) with small breasts were recruited, 20 of whom underwent subglandular injection.   Patients were treated in groups of four to enable step-wise revision of the injection technique. Safety and efficacy assessments (12-month follow-up) included adverse event (AE) reporting and the Global Esthetic Improvement Scale, respectively.

It’s a small study with the authors reporting 83% satisfaction in the post-procedure breast appearance at 6 months, 69% at 12 months.  I find it interesting that the most commonly reported adverse event was capsular contracture.   Obviously,  larger studies are needed before this can be routinely recommended to patients.

……………………….

Dentist are “pushing” their scope of practice beyond the teeth/dentition to include Botox and fillers.   While dentists may know how to do injections well and should know facial nerve/muscle anatomy well, I personally feel this is beyond the definition of dental practice.  I suppose it will be up to state dental and medical boards to work this out.

 The Evolving Role of Dentist in the Injectables Business by Jeff Frentzen, PSP Blog  leads you to the full article: The next revolution in dentistry: facial injectables by Bruce G. Freund, DDS, Oct 25, 2010.

REFERENCE

Macrolane(TM) for breast enhancement: 12-month follow-up; Per Hedén; Plastic & Reconstructive Surgery: POST ACCEPTANCE, 14 October 2010; doi: 10.1097/PRS.0b013e318200ae57; Original Article: PDF Only

Lovenox Instructions

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

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 (*******).   

Wish It Weren’t So

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

I’d love to report that doctors are always ethical and have their patient’s best interest at heart, but alas even I am not that naive. 

It is important for physicians to not mislead the public as to their training or skills.  No one expects family physicians to do liposuction surgery or eye doctors to do breast augmentations. 

Here is an article in the St. Petersburg Times by Letitia Stein from August 8, 2010:  Limited training among some cosmetic surgery doctors worries state officials. 

A Tampa doctor accused of allowing unlicensed assistants to perform liposuction should have his license suspended for a year and pay a $50,000 fine, the Florida Board of Medicine decided Saturday.

The board's action was a move to address the growing concern about physicians with limited cosmetic surgery training working in medical spas.   …………

The charges stemmed from a woman who came to Dr. Yves N. Jean-Baptiste for liposuction. Jean-Baptiste had trained and received board certification in family medicine. About two years ago, he began to perform cosmetic procedures at his north Tampa practice, YJB Medical and Weight Clinics, after completing a three-day "intensive, hands-on training course" in Weston, according to his attorney.

Jean-Baptiste said he performed more than 250 liposuction procedures, his attorney noted without serious complication. But the July 2009 case illuminated his safety breaches.

State health officials said Jean-Baptiste allowed two people unlicensed to practice medicine to perform liposuction on the patient, identified as D.S. Her medical records didn't show a proper exam before the procedure, how much anesthesia was used, or the amount of fat removed. And Jean-Baptiste hadn't registered his office, then on Gunn Highway, as a surgical facility as required.   …………..

And from Dr. Rob Oliver Jr, Plastic Surgery 101, tells us about the eye doctor who had to call 911:  Ways to (nearly) ruin your life 101 - Choosing an Atlanta eye doctor to do your breast augmentation surgery

This summer there was an awful instance of medical negligence in Georgia involving an eye-doctor (opthamologist) who had major complications while attempting to perform breast augmentation surgery in his office. You can hear a frantic 911 call from the doctor explaining that he has encountered uncontrollable bleeding he created while during her breast implant surgery and has no idea how to fix it. …….

You can view 2 video news clips on the story here & here.    ………………..

Lipodissolve “Too Good to be True”

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

I have long been skeptical of Lipodissolve claims.  Patients would ask about the injections that dissolve the fat without surgery.  How it worked?  How safe is it?  Do you do it?  Do you know anyone who does?

The FDA has finally issued a warning

On April 7, 2010, FDA announced it had sent warning letters to six medical spas in the United States—and a cyber letter to a company in Brazil—for making false or misleading statements on their Web sites about drugs used in the procedure, or for otherwise misbranding lipodissolve products.

The U.S. medical spas receiving warning letters make various unsupported claims about lipodissolve, such as assertions that the products used in lipodissolve

• are safe and effective
• have an outstanding safety record
• are superior to other fat-loss procedures, including liposuction

Notice the “unsupported claims” phrase.  I have never been able to find any good articles regarding lipodissolve so that I could intelligently answer questions regarding it. 

Lipodissolve is a procedure where the patient receives a series of drug injections intended to dissolve and permanently remove small pockets of fat from various parts of the body.   This procedure is also known as injection lipolysis, lipozap, lipotherapy, and mesotherapy.

The drugs most regularly used in the lipodissolve injection procedures are phosphatidylcholine and deoxycholate (commonly called PC and DC, respectively).  Other ingredients may also be used, including drugs or components of other products such as vitamins, minerals, and herbal extracts.

None of the drugs or products used have been approved by the FDA for fat dissolving or fat removal.

The FDA wants any potential lipodissolve patients to be aware:

• None of the drugs/products used in the procedure have been evaluated or approved by the FDA.
• The FDA is not aware of evidence supporting the effectiveness of the substances used in lipodissolve for fat elimination.
• The safety of the substances used in lipodissolve, when used alone or in combination, is unknown.
• The FDA is not aware of clinical studies to support medical uses of lipodissolve.

In addition, FDA has reports of unexpected side effects in people who’ve undergone the lipodissolve procedure.  These side effects include:

• permanent scarring
• skin deformation

deep, painful knots under the skin in areas where the lipodissolve treatments were injected

I continue to tell patients that I do not advise the use of these lipodissolve procedures.   For me (and the FDA), lipodissolve is “too good to be true.”

Keeping Patients Warm Perioperatively

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

Last week I read this article in the Medical Industry News written by Kaye Spector: Warm wakeup from surgery has roots with Cleveland doctor. I am impressed with this new patient gown that works with the Bair Hugger System (photo credit)

It would work well to pre-warm patients in the holding area. It would work well for facial, abdominal, or extremity surgery as shown in the photo. For chest case, perhaps it is possible to roll the gown downward covering the abdomen and legs. If not then the traditional lower-body Bair Hugger blanket could still be used.

If kept clean in the operating room, then it could be used in recovery to continue warming the patient there.

The 2006 article by Dr. Leroy Young on preventing perioperative hypothermia in plastic surgery patients is a very good article – well written, easy to read, covers the topic thoroughly. Here are the big suggestions for prevention given:

• Actively prewarm patients in preoperative area for approximately 1 hour with forced-air heating or resistive-heating blanket.
• Keep the ambient temperature of the operating room at a minimum of 73°F.
  
• Monitor core temperature throughout administration of general and regional anesthesia.
  
• Cover as much body surface area as possible with blankets or drapes to reduce radiant and convective heat loss through the skin.
  
• Actively warm patients intraoperatively with forced-air heaters or resistive-heating blanket to prevent heat loss and add heat content. Rearrange covers every time patient is repositioned to warm as much surface area as possible.
• Minimize repositioning time as much as possible so that the active warming method can be quickly continued.
  
• Warm intravenous fluids and/or infiltration fluids if large volumes are used. Warm incision irrigation fluids.
  
• Aggressively treat postoperative shivering with forced-air heater or resistive-heating blanket and consider pharmacologic intervention.

Perioperative hypothermia is associated with increased surgical site infections, slower wound healing, coagulation disorders, and increased bleeding. So it is very important to keep patients warm. It also makes them more comfortable, so improved hospital and surgeon ratings.

As the surgeon (and one with the occasional hot flash), I can tell you it is difficult to work in an OR with temperatures higher than 70°F. My fellow female colleagues (scrub nurses, circulating nurses, etc) at the surgery center I work most frequently often want the temperature even lower. It is a struggle to keep everyone happy and comfortable.

The article referenced below states

The minimum OR temperature recommended in the literature is 22°C (71.6°F), and most researchers agree that an ambient temperature of at least 23°C (73.4°F) is better. Sessler recommends an OR temperature of 25°C (77°F). One study by El-Gamal and colleagues determined that nearly all cases of perioperative hypothermia could be eliminated if OR temperatures were 26°C (79°F).

REFERENCES

Prevention of perioperative hypothermia in plastic surgery; Aesthetic Surgery Journal September 2006, Vol. 26, Issue 5, Pages 551-571; V. Leroy Young, Marla E. Watson

Botox Gets Bad Press

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

BOTOX has been getting a lot of bad press recently. First, the potential use of black market Botox in terroristic activity. Now it is the focus of a lawsuit in Orange County, California by a mother who alleges that the Botox treatments used to decrease muscle spasms weakened her daughters respiratory muscles, therefore causing her death.

Kristen Spears’ mother has sued Allergan alleging that her daughter died from a fatal reaction to the Botox treatments Kristen received for treatment for cerebral palsy. The trial began two weeks ago. I have looked for updates, but found none.  [update below]

BOTOX is most commonly known for it’s cosmetic uses in wrinkle reduction, but is approved by the FDA for treatment of cervical dystonia, strabismus, blepharospasm, primary axillary hyperhidrosis, and glabellar wrinkles. It is also used "off label" for a variety of more prevalent conditions that include migraine headache, chronic low back pain, stroke, traumatic brain injury, cerebral palsy, achalasia, and various dystonias.

The treatments in cerebral palsy are used to decrease muscle spasms. A multidisciplinary panel systematically reviewed relevant literature from 1966 to July 2008 and published their recommendations in the Journal Neurology:

For localized/segmental spasticity, botulinum toxin type A is established as an effective treatment to reduce spasticity in the upper and lower extremities. There is conflicting evidence regarding functional improvement. Botulinum toxin type A was found to be generally safe in children with cerebral palsy; however, the Food and Drug Administration is presently investigating isolated cases of generalized weakness resulting in poor outcomes.

Recommendations: For localized/segmental spasticity that warrants treatment, botulinum toxin type A should be offered as an effective and generally safe treatment (Level A).

Botox, manufactured by Allergan Inc., contains extremely minute quantities of Botulinum Toxin A, which causes temporary muscle paralysis. A Botox “black box” warning was ordered by the FDA in May 2009 due to reports that the effects of the toxin may spread from the area of injection to other areas of the body causing serious adverse problems. This label requirement is required on Botox and Botox Cosmetic (botulinum toxin type A); Myobloc (botulinum toxin type B); and a new FDA-approved product, Dysport (abobotulinumtoxinA).

When the botulinum toxin spreads beyond the area injected the toxin can cause symptoms similar to those of botulism. These symptoms include unexpected loss of strength or muscle weakness, hoarseness or trouble talking, trouble saying words clearly, loss of bladder control, trouble breathing, trouble swallowing, double vision, blurred vision and drooping eyelids

According to AboutLawSuits.com Allergan Inc. currently faces at least 15 Botox lawsuits that claim that the company hid the risks associated with the drug.

 

REFERENCES

LA Times

Practice Parameter: Pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review); NEUROLOGY 2010;74:336-343

 

***March 3, 2010 Update

Yesterday, Orange County Registar ran this article by Colin Stewart:  Allergan wins Botox death trial. 

By a 10-2 vote, jurors decided Tuesday that Botox-maker Allergan was not responsible for the death of a young cerebral palsy patient who died in 2007 after Botox injections.

Liposuction – Shaping not Weight-loss

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


H/T to Jeff Frentzen, PSP Blog, for the link to this article “Large Volume Liposuction - Nip/Tuck Gets It Very Wrong” by Natalie Kita (December 22, 2009)

I am not so silly as to miss seeing FX Network's plastic surgery-based drama Nip / Tuck for what it truly is: entertainment. I don't expect pinpoint scientific accuracy. However, when doing any sort of medical-based drama, doing it well requires that you must at least attempt to be somewhere in the realm of reality where the medical facts are concerned.

Last week's episode broke that rule ten times over when it portrayed a large volume liposuction case in which 150 lbs of the patient's body weight were removed during a lipo/tummy tuck combo surgery. We won't even get into the ethical considerations of sucking the fat out of a prisoner so he can be legally slim enough to receive his scheduled lethal injection. That's a blog for another day.

I have not been a fan of Nip/Tuck for several years now.  This just adds to my disdain for the show.  Be that as it may, lets look at liposuction.

Liposuction is a surgical procedure done for shaping, not weight loss.  It is considered to be one of the most frequently performed plastic surgery procedures in the United States.  Large-volume liposuction is defined as the removal of 5000 cc or greater of total aspirate during a single procedure.

A recent Aesthetic Surgery Journal article (full reference below) looked at 25 years of liposuction experience.  Their experience mirrors the history of liposuction during their study period:  July 1983 to January 2008. The liposuction techniques studied included dry liposuction, tumescent liposuction, tumescent UAL, and tumescent LAL.  Note how the technique and safety issues evolved over time.

1983-1985  Dry liposuction with 10-, 12-, and 15–mm diameter cannulas.

1985-1987  Dry liposuction with cannula diameters reduced to 5, 6, and 8 mm.  The submental area was at all times treated with a 3–mm cannula.

Liposuction was always performed in the deep plane; aspiration ceased once mostly blood was being obtained. For the first six months in which liposuction was performed, there were no parameters defining when to stop the aspiration and volumes as high as 8000 mL were obtained.
After those six months, in collaboration with the anesthesiologists, a calculation of volume reposition was made according to the aspiration obtained. For every 1000 mL extracted, there was a reposition of 1000 mL of isotonic saline solution and 1000 mL of polygeline solution (Haemaccel 3.5% colloidal intravenous infusion; Aventis, Strasbourg, France).
All patients had blood tests before surgery and 24 hours after surgery to measure hemoglobin and hematocrit values. Aspiration volumes were reduced after six months, ranging from 2000 to 4000 mL. Patients with hemoglobin values less than 8 and who experienced the symptoms of anemia (ie, increased heartbeat, low blood pressure, constant headache, dizziness, and weakness) were transfused.

1987 – present   Tumescent liposuction was performed in all patients, technique evolved over time.

At first, only isotonic saline solution was administered before aspirations.
Beginning in 1989, the infiltration solution was prepared using two adrenaline ampoules (1 mg of adrenaline per each 1 mL ampoule) per 1 L isotonic saline solution. No lidocaine was added. The solution was administered in a 1:1 ratio (the amount of solution being infiltrated was approximately the same as the aspiration obtained).
Cannula diameters were reduced to 3, 4, and 5 mm. The amount of fat extraction was limited to 5000 mL.

1998 – 1999   Ultrasound-assisted liposuction (UAL) (16000 Hz) was performed.
2007 – 2008  Laser-assisted liposuction (LAL) was performed with an internal diode laser (wavelength, 660 nm; power, 130 mW).
There were no changes in infiltration solution, volume extraction, or operating time when using either tumescent solution alone versus suction-assisted-liposuction (SAL) or LAL. Both of the latter techniques were performed using an internal cannula after the tumescent solution was applied, followed by performance of SAL.
The authors state that time frame was the main criteria for which technique was used. 

Most significantly, the use of tumescent liposuction reduced the incidence of anemia, but increased the incidence of seroma. The incidence of postoperative pain and fibrosis in our patients was similar regardless of the technique used. Aesthetic results using assisted liposuction devices in UAL and LAL procedures were similar to those achieved in tumescent liposuction.

 

 

The second reference article is from the ASPS Patient Safety Committee.  It is a great review of liposuction and it’s risks/safety.  Here is their assessment of liposuction for obesity:

Large-volume liposuction has become a technique for addressing contour irregularities, but preliminary studies also suggest improvement in cardiovascular risks, blood pressure reduction, and reduced levels of fasting insulin after liposuction.   Although liposuction may provide some physiologic benefit to the obese patient, there are inherent risks in these patients that must be considered, such as poor wound healing, increased risk of infection, deep vein thrombosis, and sleep apnea.  ……..  Liposuction is not considered a standard treatment for obesity.

Also from the same Safety Committee Advisory:

When referring to liposuction volume, total aspirate should be the volume recorded. Some states have imposed restrictions pertaining to the aspirate volume and surgical facility; these limits range from 1000 to 5000 cc (e.g., California, Florida, Kentucky, New York, Ohio, and Tennessee). Surgeons should consult their individual state regulations; however, it is the position of American Society of Plastic Surgeons that, regardless of the anesthetic method, large-volume liposuction (>5000 cc of total aspirate) should be performed in an acute-care hospital or in a facility that is either accredited or licensed. Postoperative vital signs and urinary output should be monitored overnight in an appropriate facility by qualified and competent staff members who are familiar with the perioperative care of the liposuction.

 

It must be remembered that liposuction is surgery.  As with all surgeries, complications can occur.  Minor complications that resolve on their own or with little additional treatment include small hematomas, seromas, and minor contour irregularities.  More severe complications are rare, but  include skin perforation, major contour defects, skin necrosis, thermal injury, vital organ injury, adverse anesthesia reaction, major hemorrhage, ischemic optic neuropathy, deep vein thrombosis, pulmonary embolism, and fat embolism. 

 

 

REFERENCES

Liposuction: 25 Years of Experience in 26,259 Patients Using Different Devices; Aesthetic Surgery Journal, Vol 29 (6), pp 509-512; Lina Triana, Carlos Triana, Carlos Barbato, Marco Zambrano
Evidence-Based Patient Safety Advisory: Liposuction; Plastic and Reconstructive Surgery. 124(4S):28S-44S, October 2009; Haeck, Phillip C.; Swanson, Jennifer A.; Gutowski, Karol A.; Basu, C Bob; Wandel, Amy G.; Damitz, Lynn A.; Reisman, Neal R.; Baker, Stephen B.; the ASPS Patient Safety Committee

DVT Screening and Prevention

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

Last week the National Institute for Health and Clinical Excellence (Nice) published it’s report calling for DVT screening of all patients admitted to the hospital in Great Britain.   You can read the Quick Reference Guide here (pdf file).  Seems like a good time to review the subject.

From the prevention side in surgical patients, here are a few things to remember. Patients are ranked into risk categories. These are:

• Low: Minor procedure, Patient less than 40 yrs old, No other risk factors
• Moderate: Minor procedure, Age between 40-60 yrs, No other risks factors
• High : Non-minor (major) procedure, More than 60 yrs, No other risks factors
  Or Age between 40-60 yrs with other risks factors
• Highest: Major procedure, Multiple risk factors, Hip/knee arthroplasty, Hip fracture surgery, Major trauma, Spinal cord injury

Other risks factors include: recent pregnancy (less than one month ago) [This is why, along with the recent blood loss of delivery, and often anemia of pregnancy that women should never have a tummy tuck at the time of their C-section. The risks are too high for complications.], varicose veins, overweight, personal or family history of blood clots, personal history of cancer, use of birth control or hormone replacement, recent travel (long flights or car rides without movement), etc. Recall the journalist who died after sitting in a tank for long hours with little to no movement.

 

Preventive Therapy consists of:
All surgical patients should have intermittent pneumatic compression devices used (unless the procedure will be less than 1 hour) during the surgical procedure.

• 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 (will depend on the procedure being done and on patient history)
  

REFERENCES

1.  Prevent DVT.org

2.  Prevention of Venous Thromboembolism in the Plastic Surgery Patient; Plastic and Reconstructive Surgery, Vol 114 (3) September 1, 2004, pp 43e-51e.

3.   Deep Venous Thrombosis Prophylaxis Practice and Treatment Strategies among Plastic Surgeons: Survey Results, Plastic and Reconstructive Surgery; Vol 119 (1) January 2007, pp 157-174.

4.   Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians

5.   Current and Emerging Therapies in the Management of Venothromboembolism by Jack E. Ansell MD, Samuel Z. Goldhaber MD, Ajay K. Kakkar MBBS, Graham Turpie MD -- Medscape Article Dec 28, 2007

6.   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.

7.  Executive Summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition); Chest June 2008 133:71S-109S; doi:10.1378/chest.08-0693

Smoking in Facial Aesthetic Surgery Patients

Just finished reading a CME article on “Aesthetic  Surgery of the Face and Neck” in the Nov/Dec issue of the Aesthetic Surgery Journal (the first article referenced below).  Nice review article, but I want to just concentrate on the section on smoking.  This is the time of year when many resolutions are made, and often to quit smoking is one of them. 

One of the major things to avoid pre- and post-facial surgery is smoking.  The other major one is platelet inhibitors (ie aspirin, NSAIDs, and certain herbals).

The logic for smoking avoidance is because “tobacco smoke is an aerosol of particulate matter, volatile acids and gases.  The overall cellular effect of these inhaled or absorbed byproducts is to produce an environment of relative tissue hypoxia, and delayed wound healing mediated by vasoconstriction, abnormal cellular function, and thrombogenesis.” [second reference]

The reported incidence of facelift skin flap necrosis is 12.5 times greater in smoker than nonsmokers.  This risk is too high for elective surgery, so no surgeon will knowingly operate on the face of a smoker electively.

Even smoking one cigarette has been shown to cause temporary vascular spasm which can last up to one hours.  This vascular spasm can result in 24-42% decrease in blood flow.  This can lead to skin necrosis, poor wound healing, and increase infection.

The current recommendation for elective facial surgery is smokers is patients remain nicotine-free for four weeks before surgery and for four weeks after surgery.

Patients often underreport their smoking.  To “test” their truthfulness, a salivary rapid test (NicAlert) has been developed which test for cotinine, the metabolic breakdown product of nicotine.

I would encourage all smokers to quit just for general health benefits.  Keep trying.  If one method doesn’t work for you, work with your primary care physician to find one that does.

 

 

REFERENCE

Aesthetic Surgery of the Face and Neck; Aesthetic Surgery Journal, November 2009, Vol. 29, Issue 6, Pages 449-463; Fritz E. Barton (DOI: 10.1016/j.asj.2009.08.021)

Clearing the Smoke:  the Scientific Rationale for Tobacco Abstention with Plastic Surgery; Plastic and Reconstructive Surgery. 108(4):1063-1073, September 15, 2001; Krueger, Jeffery K.; Rohrich, Rodney J.

The Effect of Cigarette Smoking on Skin-Flap Survival in the Face Lift Patient; Plastic and Reconstructive Surgery. 73(6):911-915, June 1984; Rees, Thomas D.; Liverett, David M.; Guy, Cary L.

Planning Elective Operations on Patients Who Smoke: Survey of North American Plastic Surgeons; Plastic and Reconstructive Surgery. 109(1):350-355, January 2002; Rohrich, Rod J.; Coberly, Dana M.; Krueger, Jeffery K.; Brown, and Spencer A.

Pumpkin Carving Safety Tips

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

It’s that time of year again!  Here’s a reposting of  my post from last year.  Enjoy, but be careful!

Carved pumpkins can be works of art, but carving one incorrectly can leave you with cut fingers. Minor cuts will often stop bleeding on their own or by applying direct pressure to the wound. Most of these cuts and scraps will be minor and can be treated by washing with soap and water initially. 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. (photo credit--Headless Horseman)

Let's prevent the injuries. 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. (photo credit)

Here is a link for instructions and patterns for pumpkin carving at Spook Master.  For some amazing photos of carved pumpkins, check out this Tayyerit Presents.  You can find photos from 1998 to present.  Absolutely amazing!

Here are just some fun photos I found:

Happy Halloween (video of Jim Hendricks, bbc.co.uk)

Ping the Pug (photo credit)

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

Have a safe Halloween season!

Weight Lifting Good for Breast Cancer Patients

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

Historically, we healthcare providers have cautioned breast cancer patients to avoid weight training after a mastectomy and or axillary dissection.  We often use 15 lbs as a guideline for a save weight to lift using the arm on the mastectomy side.  A new study suggests this advice turns out to be misguided.

The study has been published in the August 13 issue of the New England Journal of Medicine.  It is a small study, but the results do challenge our current reluctance to allow lymphedema patients to weight-lift.

Kathryn Schmitz, PhD, MPH and colleagues enrolled 141  breast cancer survivors with lymphedema.   The enrollees were then placed into two groups.  One was assigned to a weight-lifting group who lifted twice-weekly for 13 weeks.  The other group was used as a control group and did no weight-lifting.

The weight-lifting women (71) wore a custom-fitted compression garment on their affected arm during their workouts.  Their arms were measured monthly to ensure any changes were noted as soon as they occurred.  Each week were asked about changes in symptoms.

Both groups had the same proportion of women who experienced an increase of 5% or more in their limb swelling.  However, the weight-lifting group had fewer exacerbations of their condition which required treatment from a physical therapist; 9 compared to the 19 women in the control group.   The weight-lifting group also had a reduction in symptoms such as pain.

Further studies need to be done to verify their results, but I would allow motivated patients to begin weight-lifting with a slow, progressive program.   They should learn proper technique.  They should wear their custom-fit compression garment during all exercise sessions.

Weight-lifting has been shown to decrease bone loss which is important in these women as in all women.  Having more strength can also aid in everyday activities like carrying bags of groceries or carrying children/grandchildren.

REFERENCE

Weight Lifting in Women with Breast-Cancer–Related Lymphedema; New England Journal Medicine, Vol 361 (7):664-673, August 13, 2009; Kathryn H. Schmitz, Ph.D., M.P.H., Rehana L. Ahmed, M.D., Ph.D., Andrea Troxel, Sc.D., Andrea Cheville, M.D., Rebecca Smith, M.D., Lorita Lewis-Grant, M.P.H., M.S.W., Cathy J. Bryan, M.Ed., Catherine T. Williams-Smith, B.S., and Quincy P. Greene

Related Posts

Lymphedema (December 5, 2007)

ARM Technique (October 15, 2008)

Tanning Beds = High Cancer Risk

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

Finally!  [H/T to Cleveland.com]

After surgery I am often asked, “When can I get back in the tanning bed?”  I say something like, “I would rather you not use a tanning bed.  You need to protect you new scar from the sun, that includes tanning beds, for at least 6 months.”

“But, if I cover up the scar, when can I get back in the tanning bed?” is the usual response.

I then counter with, “IF you feel you must, then yes cover the scars.  Please, limit or reduce the time you spend in the tanning bed.  I would rather you not use a tanning bed.”

Most see “no harm” in using a tanning bed.  After all, it’s not like laying out in the sun for hours.  Too many see tanning beds as a “safe” way to get a tan.  It isn’t.

Experts at the International Agency for Research on Cancer in Lyon, the cancer arm of the World Health Organization, have published their analysis of 20 studies online in the medical journal Lancet Oncology.  The analysis concludes the risk of skin cancer jumps by 75 percent when people start using tanning beds before age 30.

These same experts have moved tanning beds and ultraviolet radiation into the top cancer risk category, deeming both to be as deadly as arsenic and mustard gas.  The new classification also puts them in the list of definite causes of cancer, alongside tobacco, the hepatitis B virus and chimney sweeping, among others.

I would not mind tanning bed extinction.  Regular use increased the risk of melanoma.  It is much better to have a “peaches and cream” complexion or to use self-tanning creams.  Skin cancer is no fun.

Related posts:

Sun Protection (March 19, 2009)

Melanoma Review (February 25, 2008)

Skin Cancer—Melanoma (December 8, 2008)

Melanoma Skin Screening Is Important (April 29, 2009)

Skin Cancer -- Basal Cell Carcinoma  (December 3, 2008)

Skin Cancer – Squamous Cell Carcinoma  (December 4, 2008)

Moles Should Not Be Treated by Lasers  (July 27, 2009)

Moles Should Not Be Treated by Lasers

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

 

H/T to DermDoc who treated this news article link.  The article is “Some Laser Treatments Could Put Health At Risk, Dermatologists Say.”

dermdoc  Medical Spas Removing Moles with Lasers <-- Dangerous. Melanoma looks like a mole. http://tinyurl.com/m2pqmo  3:13 PM Jul 20th from web

He then followed up with this tweet

dermdoc  Medi-Spas are spas. Never have a mole removed without being checked by a physician. @serious_skeptic @nanarcr  3:29 PM Jul 20th from web

I agree.  It can be difficult even for trained physicians to tell the difference between moles and melanoma.  Don’t allow spas to laser them.  If there is any question, the mole should be biopsied.  That doesn’t happen with “laser treatment.”

To further make this point, check out the slide show on Medscape (free subscription required)

Mole or Melanoma? Tell-Tale Signs in Benign Nevi and Malignant Melanoma: Slideshow  Can you spot the differences between benign and potentially malignant nevi? Would you be able to tell which require a biopsy?

Related Posts
Melanoma Review (February 25, 2008)
Skin Cancer—Melanoma (December 8, 2008)
Melanoma Skin Screening Is Important (April 29, 2009)
Skin Cancer -- Basal Cell Carcinoma  (December 3, 2008)
Skin Cancer – Squamous Cell Carcinoma  (December 4, 2008)

Plastic Surgery for Fighters

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

Not sure what I think about this trend of plastic surgery for fighters discussed in this New York Times article -- Cut-Prone Fighters Turn to Surgery to Limit Bleeding by R.M. Schneiderman (Published: July 10, 2009).  

In 16 years as a professional boxer and mixed martial arts fighter, Marcus Davis has received stitches above his eyes 77 times. The cuts have affected him: doctors have stopped fights, and his battered face, he says, has influenced judges’ decisions.

So last summer, Davis, 35, contacted a plastic surgeon in Las Vegas. He wanted to make his skin less prone to cutting.

The surgeon, Dr. Frank Stile, burred down the bones around Davis’s eye sockets. He also removed scar tissue around his eyes and replaced it with collagen made from the skin of cadavers.

Now, at least in theory, when Davis takes a blow to the face, he will be less likely to bleed.

Medical researchers have not analyzed the procedure, and until they do, the American Society of Plastic Surgeons will not comment on its efficacy. But Davis and several others swear by it.

I can understand why the ASPS won’t comment.  I have no problem revising scars for anyone who is realistic with what can be accomplished.  Prominent brows are smoothed down (not in my practice, as I mostly do body work) for cosmetic reasons -- orbital rim contouring or brow shave. 

It is neither of those that gave me pause when I read the article on plastic surgery for fighters.  It is the question of real or implied promise of the surgery decreasing the risk of “bleeding” or “cutting” that gives me trouble.  Possibly it does. 

Surgery always carries risk.  In this population, maybe less than the chosen occupation of boxing or martial arts fighting, but still it carries risks.  There is the risk of infection (skin and sinuses), bleeding, and scarring.   Would I tell the young man that his risk of “cutting” would be 50% less or 15% less or 65% less?  Wouldn’t he need that information in making the decision to proceed with the surgery if his reason was not for cosmetic purposes but the goal of less “cutting”?

…………………………………………………

The degree of supraorbital bossing usually falls within three groups.  X-rays or head CT scan is needed preop to determine the bone thickness over the frontal sinuses.

• Group 1 are those with minimal to moderate anterior projection of the supraorbital rims and thick skull bone over the frontal sinus and/or absence of the frontal sinus.  These deformities can be corrected by bone reduction alone utilizing a surgical burr.
• Group 2 are those with minimal to moderate anterior projection of the supraorbital rims but with relatively thin bone over the frontal sinuses of normal size. Correction requires completing as much contouring of the bones as possible without entering the sinus.
• Group 3 are those with severe anterior projection of the supraorbital rims is so excessive that adequate bone reduction contouring is impossible without entering the frontal sinus.   These require obliteration and filling of the sinuses in order to reduce the contour enough.