Two Articles on Bone Biology

There are two good articles worth reading on bone biology and physiology in June 2012 issue of Journal of Plastic and Reconstructive Surgery. 

The first one is a good review of the basics, blood supply, cell types, bone matrix, bone formation, bone growth, and bone remodeling.  The second article then uses the first to discuss clinical correlates.

Bone Biology and Physiology: Part I. The Fundamentals; Buck, Donald W. II; Dumanian, Gregory A.; Plastic & Reconstructive Surgery. 129(6):1314-1320, June 2012; doi: 10.1097/PRS.0b013e31824eca94

Bone Biology and Physiology: Part II. Clinical Correlates; Buck, Donald W. II; Dumanian, Gregory A.; Plastic & Reconstructive Surgery. 129(6):950e-956e, June 2012; doi: 10.1097/PRS.0b013e31824ec354

Shout Outs

Updated 3/2017 -- all links removed (except to my own posts) as many no longer active.


My thanks to @jordangrumet for this tweet.  It gave me the motivation I needed to sit down and write.  I have lacked it lately, unsure where my blog is headed with the job transition, not wanting to lose contact with my fellow bloggers.  So thanks, Jordan. 

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Glass Hospital is the host for this week’s Grand Rounds.  You can read this week’s edition here.

Welcome to Grand Rounds, where writers, readers, and bloggers send in their best stuff on a weekly basis to share, cross-pollinate, and build new audiences.

Tip of the hat to Grand Rounds co-creator Nick Genes, MD, PhD, an ER doc in NYC who knows a thing or two about blogging, tweeting and now Tumblr.

a timeless and inspiring read...

The theme of this week’s Grand Rounds is “Finding Meaning in Medicine,” with full attribution to Dr. Rachel Naomi Remen, author of the masterful book Kitchen Table Wisdom: Stories that Heal.  …………..

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H/T to @medicallessons who tweeted about this very unusual medical case in the NEJM:  Disappearance of a Breast Prosthesis during Pilates (includes images)

A 59-year-old woman with a history of breast cancer who underwent bilateral mastectomy and placement of breast prostheses presented for evaluation, reporting that her “body swallowed one of the implants” during a Pilates stretching exercise ….

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Another plastic procedure gone awry documented in a NEJM case report (h/t to @Neil_Mehta):  Blindness after Fat Injections

A 32-year-old man presented with vision loss in the left eye. one week earlier, while under local anesthesia, he had had an autologous fat injection into his forehead for correction of glabellar frown lines. The patient reported that while he was receiving the injection, he felt a sudden, severe periocular pain and had complete vision loss in his left eye. …..

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I found out via a Christmas card I received last week that a classmate from medical school was diagnosed with early mild cognitive impairment(mci) amnestic type last December.  He began writing a blog to chronicle his journey as he progresses towards Alzheimer's disease:  organicgreendoctor. 

He was a Family Practice doc before he retired.  He was/is a super nice guy.

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TBTAM has finally (smile) gotten around to giving us a list recommended NYC Restaurants

Home cooking is what I do best. And yet, the most frequent e-mail request I get from readers, friends and family is – “Where should we eat when we come to New York?”  And so, after years of wracking my brain for recommendations, I decided to create a list here of the places I go to and like. Some I’ve reviewed here on the blog – Most I have not (even though I have dozens of pics  and the best of intentions). But let me be clear – I am not a restaurant connoisseur. I’m just an ordinary New Yorker who knows what she likes. …..

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I never get around to reading all the books recommended to me, but still…  Here’s a list from Seattle Times reviewers:  32 of the year's best books

………Here are the results — 32 books, 21 fiction (who says the novel is dead!?), 11 nonfiction. Top vote getters were three novels, "The Sense of an Ending" by Julian Barnes, "The Marriage Plot" by Jeffrey Eugenides and "Ed King" by David Guterson, and Erik Larson's work of nonfiction, "In the Garden of Beasts." ……..

Sutureless Blood Vessel Repair

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

If this works in humans as it has in rats, then it will be a huge advance in microvascular repair.  The full article is referenced below (I did not read in it’s entirety due to pay wall).   (photo credit)

We have developed a new method of sutureless and atraumatic vascular anastomosis that uses US Food and Drug Administration (FDA)-approved thermoreversible tri-block polymers to temporarily maintain an open lumen for precise approximation with commercially available glues. We performed end-to-end anastomoses five times more rapidly than we performed hand-sewn controls, and vessels that were too small (<1.0 mm) to sew were successfully reconstructed with this sutureless approach. Imaging of reconstructed rat aorta confirmed equivalent patency, flow and burst strength, and histological analysis demonstrated decreased inflammation and fibrosis at up to 2 years after the procedure. This new technology has potential for improving efficiency and outcomes in the surgical treatment of cardiovascular disease.

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Currently, vascular microanastomosis (photo credit) is done by suturing.  Arteries 1 mm in diameter usually require 5 to 8 stitches, and veins require 7 to 10 stitches.  There is a risk of thrombosis even with the most meticulous repair -- total thrombosis rate 8%, with  no significant patency difference noted between the continuous suture technique and the interrupted suture technique in any vessel category.

REFERENCE

1.  Vascular anastomosis using controlled phase transitions in poloxamer gels; Edward I Chang, Michael G Galvez, Jason P Glotzbach, Cynthia D Hamou, Samyra El-ftesi, C Travis Rappleye, Kristin-Maria Sommer, Jayakumar Rajadas, Oscar J Abilez, Gerald G Fuller, Michael T Longaker, Geoffrey C Gurtner;  Nature Medicine, 2011; DOI: 10.1038/nm.2424

2.  Sutureless Method for Joining Blood Vessels Invented; ScienceDaily (Aug. 28, 2011)

3.  Technique for Microanastomosis; Wheeless Textbook of Orthopaedics, June 28, 2011

4.  Vascular Skills Lab Two (pdf)

Does Negative Pressure Promote Wound Healing? -- article review

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

There was a recent EurekAlert which caught my attention:  No healing in a vacuum. 

Negative-pressure wound therapy probably does not promote healing. This is the conclusion of Frank Peinemann and Stefan Sauerland's meta-analysis in the current edition of Deutsches Ärzteblatt International (Dtsch Arztebl Int 2011; 108[22]: 381-9).

The press release actually contained a link to a pdf file of the article (full reference and link below).

Negative-pressure wound therapy (NPWT), also known as vacuum assisted closure,  involves covering the wound with an an airtight film and an adjustable negative pressure is applied using an electronically controlled pump.  The vacuum or negative pressure drains wound exudate.   NPWT is used for chronic persistent wounds and complicated wounds.

The article by Peinemann and Sauerland is a systematic review of the literature (English and German), aimed at  evaluating wound healing and adverse events following NPWT in comparison to conventional treatment in patients with acute or chronic wounds.  From the beginning summary:

We found reports of 9 RCTs in addition to the 12 covered by earlier IQWiG reviews of this topic. Five of the 9 new trials involved NPWT systems that are not on the market. The frequency of complete wound closure is stated in only 5 of the 9 new reports; a statistically significant effect in favor of NPWT was found in only two trials.The results of 8 of the 9 new trials are hard to interpret, both because of apparent bias and because diverse types of wounds were treated.

Data analysis used complete wound closure as the primary endpoint.  This was based on the U.S. Food and Drug Administration’s (FDA) 2006 Guidance for Industry definition for complete wound closure as “skin closure without drainage or dressing requirements.”

The following dependent variables were used as secondary endpoints:
● Adverse events, such as death, secondary amputations, fistula formation, and wound infection
● Time to complete wound closure
● Reduction in wound size
● Health-related quality of life.

In the discussion section of the article, some key summaries:

Regarding the primary endpoint of “wound closure” – results were not homogenous.  The authors notes it is currently impossible to be sure that NPWT performs better than control treatments.

Regarding the secondary endpoints

– Most articles reported “time to wound closure”  occurred quicker in NPWT groups.  The authors note “However, there were considerable differences between trials in terms of the methods used to measure and evaluate wound closure; particularly problematic is the fact that no blinding was used when this endpoint was measured.”  So for now, as with the  primary endpoint, it remains undecided.

--  The results on adverse events were not homogenous and varied depending on the specific complications.   For a number of other adverse events no statistically significant difference was detected.

The authors note that most trials of NPWT were conducted in hospitals.  They make this point in regard to the FDA report (3rd reference below):

The FDA recently issued a report on six deaths and 77 other complications that were reported within a two year period in connection with NPWT . All the deaths were caused by acute hemorrhages, and known contraindications for NPWT (e.g. a large blood vessel
exposed) had clearly been overlooked. Many of the deaths occurred in outpatient care or care homes, which highlights the need to monitor therapy.

The authors conclusion:

Although NPWT may have a positive effect on wound
healing, there is no proof that it is either superior or inferior to conventional wound treatment. Further RCTs of good methodological quality are required.

REFERENCES

Peinemann F, Sauerland S: Negative pressure wound therapy—systematic review of randomized controlled trials; Dtsch Arztebl Int 2011; 108(22): 381–9; DOI: 10.3238/arztebl.2011.0381

An introduction to the use of vacuum assisted closure by Steve Thomas, PhD--World Wide Wounds (Last updated: May 2001)

FDA: Serious complications associated with negative pressure; 2009 (last updated 02/24/2011)

Advances in Surgical Treatment of Facial Nerve Paralysis in Children – an article review

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

I read the second article below first.  I was struck by the opening paragraphs of Daniel Alam, MD’s commentary which note the importance of smiling in human communication and how it is often taken for granted EXCEPT by those who have lost the ability to smile.

This is far from the case for patients who have lost the ability to smile. Patients who have endured facial paralyses (even in the transient cases that occur in certain idiopathic facial nerve palsies, ie, Bell palsy) understand the true psychological effects of this disability. …...

I can attest to this on a personal level having had Bell’s palsy in 2002.  I have a quilt I’d like to make, a personal portrait ala Picasso, that would reflect the way it affected me.  I can’t seem to get it worked out yet, but will.

Back to these articles.  Alam commends Hadlock and colleagues (the first article below) for not just relying on emotional checks from the patients who often feel any improvement is a great result (bold emphasis is mine):

… Although this report is another well-designed clinical series of a well-established surgical technique, the true significance of this work extends far beyond the patients presented. ….This group, more than any other in facial plastic surgery, has made a concerted effort to quantify (to measure and validate) the outcomes they report. …

With that recommendation went looking for the Hadlock’s article.  

Hadlock and colleagues begin with background information which notes “free muscle transfer for facial reanimation has become the standard of care in recent decades and is now the cornerstone intervention for dynamic smile reanimation.”

While myriad muscles have been transferred into the face to restore the smile, most large series describe the use of the gracilis muscle, the latissimus dorsi muscle, or the pectorals minor.  Of these, the gracilis muscle is the most widely used, based on predictable pedicle anatomy, an acceptable donor deficit and scar, and favorable muscle microarchitectural features resulting in fast and robust excursion when activated.

Hadlock and colleagues used their SMILE program to objectively measure the functional outcome of 17 pediatric patients who had undergone 19 consecutive pediatric free gracilis transplantation operations.  The procedures were done over a 5-year period from October 2004 through September 2009.  The mean age of the patients was 11.5 years (range, 4-18 years).

All patients were prospectively administered the Facial Clinimetric Evaluation (FaCE) instrument which is a validated, standardized QOL instrument for patients with facial movement disorders.   Hadlock’s article referenced the Laryngoscope (3rd reference below) article for FaCE.

Hadlock and colleagues results

The mean commissure excursion improvement was 8.8 mm ± 5 mm (Figure 4), commensurate with the findings in other facial reanimation series.   When subdivided into those driven by a cross-face nerve graft vs those driven by the masseteric branch of the trigeminal nerve, the latter provided more excursion on average, as expected.

There was only one muscle failure in the series.  It resulted from an arterial thrombosis.
In conclusion:

In conclusion, free gracilis transfer for smile reanimation in children carries an acceptable failure rate, significantly improves smiling, and seems to improve QOL with respect to facial function. It should be a cornerstone intervention in the appropriately counseled patient and family. Because it carries a lower failure rate than a similar cohort of adult patients, there is no need to wait until patients reach adulthood to offer dynamic reanimation. Early facial reanimation provides the advantage of permitting children to express themselves nonverbally through smiling and may in fact lead to fewer negative social consequences as they interact with peers.

REFERENCES

1.  Free Gracilis Transfer for Smile in Children:  The Massachusetts Eye and Ear Infirmary Experience in Excursion and Quality-of-Life Changes; Hadlock TA, Malo JS, Cheney ML, Henstrom DK; Arch Facial Plast Surg. 2011;13(3):190–194; doi: 10.1001/archfacial.2011.29

2.  Advances in Surgical Treatment in Facial Nerve Paralysis in Children (commentary); Daniel Alam, MD; AMA. 2011;305(20):2106-2107;  doi: 10.1001/jama.2011.689

3.  Validation of a patient-graded instrument for facial nerve paralysis: the FaCE scale; Kahn JB, Gliklich RE, Boyev KP, Stewart MG, Metson RB, McKenna MJ; Laryngoscope. 2001;111(3):387–398.

Caring for Horse and Donkey Bite Wounds

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

Earlier this week this tweet from @prsjournal caught my eye

Most Popular: Management of Horse and Donkey Bite Wounds: A Series of 24 Cases: No abstract available http://bit.ly/lgNkCS

I missed this article when it came out in the June 2010 issue of the Plastic and Reconstructive Surgery Journal.  As I have covered fire ant bites, cat bites, and snake bites.  Fellow blogger Bongi has written about hippo bites.  It’s time to cover horse and donkey bites. 

Dr. Köse, Department of Plastic and Reconstructive Surgery, Harran University Hospital, Turkey and colleagues presented a retrospective evaluation of 24 patients treated for animal bites (19 horse and five donkey bites) from 2003 to 2009.  The head and neck were the most frequent bite sites (14 cases), followed by the extremities (8 cases) and the trunk (2 cases).

The article is very short, representing their personal viewpoint and experience. 

Our experience shows the safety of primary closure for horse and donkey bite wounds, provided that careful debridement and good cleansing with antibiotic prophylaxis are also performed. An acceptable aesthetic outcome can be achieved only with early primary repair and reconstructive procedures.

Dr. Köse note that horse and donkey bites often result in tissue loss wounds.  Their review of the literature (not sure how extensive) found one reported case of anaphylaxis after a horse bite and one case of a deep crush injury with hematoma, fat necrosis, and muscle rupture without an external wound in a woman bitten on her thigh by a horse.

As I shared in my post Assessing and Managing Mammal Bites – an Article Review

• Thoroughly examine patients with bites.  Especially with children, check the entire body to identify additional injuries.
  
• Examine the wound itself meticulously. It’s easy to miss things.
• Be alert for injuries to the vasculature, nerves, tendons, bones, and joints.
• Bites from large mammals can damage and even fracture bone.  Plain radiographs should be viewed after the exam.
• Large mammals who bite and shake can dislocate joints. Have patients perform active range-of-motion with joints that are near bite wounds.
• Use plain radiography to assess for retained foreign bodies and skeletal injuries. Computed tomography and magnetic resonance imaging have increased sensitivity for foreign bodies and subtle fractures.

As with all wounds, standard wound care applies.  This means copiously irrigate and debride as needed.  Bites are tetanus-prone wounds. Review the patient’s immunization records.  Give updates, etc as needed.

REFERENCE

Management of Horse and Donkey Bite Wounds: A Series of 24 Cases; Köse, Rüstü; Sögüt, Özgür; Mordeniz, Cengiz; Plastic & Reconstructive Surgery. 125(6):251e-252e, June 2010; doi: 10.1097/PRS.0b013e3181d515dd

New Research in Prevention of Keloid Scars

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

A keloid scar is the result of an abnormal proliferation of scar tissue that forms at the site of an injury to the skin (eg, on the site of a surgical incision or trauma).  Keloid scars do not regress.  They grow beyond the original margins of the scar which differs from hypertrophic scars which while raised do not grow beyond the boundaries of the original wound.  Hypertrophic scars may reduce over time. 

Keloid scars tend to recur after excision so anything that can help me prevent their formation is welcome.

I stumbled across this press release a few weeks ago.  It explains the findings published in the article (first reference below) published online January 21, 2011in the British Journal of Dermatology which notes a possible molecular target in the prevention of keloid scarring.

Collagen triple helix repeat containing-1 protein (CTHRC1) inhibits the transforming growth factor (TGF)-β1-stimulated collagen production that occurs in keloid scar formation, report researchers.

"Keloids are manifestations of an abnormal process of tissue repair after trauma to the skin. Options for treatment are limited because of lack of understanding of the molecular and cellular mechanisms governing the formation," explain Hongxiang Chen (Huazhong University of Science and Technology, Wuhan, China) and colleagues.

"Increased understanding of the role of TGF-β signaling in keloids makes manipulation of TGF-β an attractive therapeutic strategy," they say.

CTHRC1 is expressed in the adventitia and neointima on arterial injury. Chen and team assessed regulation of the CTHRC1 gene, its interaction with TGF-β1, and its possible role in keloid scar formation in fibroblast cells from keloid tissue and normal skin.

TGF-β1 and CTHRC1 were localized to the dermis in both normal and keloid skin fibroblasts. Expression of both factors were increased in keloid compared with normal skin and CTHRC1 appeared to increase in a TGF-β1 concentration-dependent manner.

When keloid fibroblasts were treated with TGF-β1 (10 ng/ml), cell proliferation increased dramatically, specifically, collagen type I synthesis was preferentially stimulated.

However, when recombinant CTHRC1 was added to the TGF-β1-treated keloid cells, the proliferation effect was reversed and excess collagen synthesis was inhibited.

Notably, treatment with recombinant CTHRC1 appeared to have no adverse effects on cell viability.

"Our data indicated that TGF-β1 was overexpressed in keloid fibroblasts and recombinant CTHRC1 could reverse TGF-β1-induced collagen type I expression at least in part by decreasing collagen synthesis," conclude the authors.

"As a potent negative regulator of collagen matrix deposition, CTHRC1 may have therapeutic value in antifibrotic treatment strategies," they suggest.

It would be nice if someday this research lead to a “prevention” therapy.


Related posts:
Scars and Their Therapy – an Article Review  (January 21, 2009)
Fluorouracil Treatment of Problematic Scars – an Article Review  (April 1, 2009)
Scar Scales and Measuring Devices  (September 8, 2010)
 

REFERENCES

1.  Collagen triple helix repeat containing 1 inhibits TGF-β1-induced collagen type I expression in keloid; J. Li, J. Cao, M. Li, Y. Yu, Y. Yang, X. Xiao, Z. Wu, L. Wang, Y. Tu, H. Chen; British Journal of Dermatology, January 2011, DOI: 10.1111/j.1365-2133.2011.10215.x

2.  Treatment of a Postburn Keloid Scar with Topical Captopril: Report of the First Case; Ardekani, Gholamreza Safaee; Aghaie, Shahin; Nemati, Mohammad Hassan; Handjani, Farhad; Kasraee, Behrooz; Plastic & Reconstructive Surgery. 123(3):112e-113e, March 2009; doi: 10.1097/PRS.0b013e31819a34db

3.  Correction: Treatment of a Postburn Keloid Scar with Topical Captopril: Report of the First Case; Plastic & Reconstructive Surgery. 123(6):1898, June 2009; doi: 10.1097/PRS.0b013e3181abc4b4

4.  Keloid and Hypertrophic Scar; eMedicine article, May 2010; Brian Berman, MD, PhD, Whitney Valins, Sadegh Amini, MD, Martha H Viera, MD

5.  Wound Healing, Keloids; eMedicine article, June 26, 2009; R Edward Newsome, MD, Ravi Tandon, MD, Robert P Bolling, MD, MPH, Alun R Wang, MD, PhD, David A Jansen, MD

BDD Patients Can Get Better

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

The Science Daily article, Body dysmorphic disorder patients who loathe appearance often get better, but it could take years, discusses the The Journal of Nervous and Mental Disease (JNMD) article (full reference below, abstract available for free).  

The JNMD article reports the results of the longest-term study so far to track people with body dysmorphic disorder.  The study was conducted by researchers at Brown University and Rhode Island Hospital.

The good news:  the researcher “found high rates of recovery, although recovery can take more than five years.”

This is a small study with only 15 BDD patients who were followed over an eight-year span.

After statistical adjustments, the recovery rate for sufferers in the study over eight years was 76 percent and the recurrence rate was 14 percent. While a few sufferers recovered within two years, only about half had recovered after five years.

The subjects were a small group diagnosed with the disorder out of hundreds of people participating in the Harvard/Brown Anxiety Research Project (HARP). Study co-author Martin Keller, professor of psychiatry and human behavior and principal investigator of the HARP research program which has been ongoing for more than 20 years, said that because the BDD sufferers were identified through this broader anxiety study, rather than being recruited specifically because they had been diagnosed with BDD, they generally had more subtle cases of the disorder than people in other BDD studies. In comparing the HARP study with the prior longitudinal study of BDD, it is possible that the high recovery rate in the HARP study is due to participants having less severe BDD on average.

Body Dysmorphic Disorder

• In its simplest definition, it is an obsessive preoccupation with a slight, imperceptible, or actually nonexistent anatomic irregularity to the degree that it interferes with normal adjustment within society.
  
• This disorder may be present in varying degrees. It is the most common aberrant personality characteristic seen by the plastic surgeon.
  
• When postoperative dissatisfaction occurs (and in most cases, it will), it almost always is based on what the patient understood rather than what was actually said.
  

….
Related posts
Suitability (January 3, 2008)
The Barbie Syndrome  (March 25, 2010)
….

REFERENCE

The Clinical Course of Body Dysmorphic Disorder in the Harvard/Brown Anxiety Research Project (HARP); Andri S. Bjornsson, Ingrid Dyck, Ethan Moitra, Robert L. Stout, Risa B. Weisberg, Martin B. Keller, Katharine A. Phillips;  The Journal of Nervous and Mental Disease, 2011; 199 (1): 55 DOI: 10.1097/NMD.0b013e31820448f7

Body Dysmorphic Disorder; eMedicine Article, September 3, 2010; Iqbal Ahmed, MBBS and Lawrence Genen, MD, MBA

Factitious Disorder?

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

Have you ever seen a case of factitious disorder?  Ever had a patient who’s wound just wouldn’t heal in spite of all the good care you gave them, all the blood work you checked (ie nutrition, infection, etc)?  Ever wondered if perhaps this nice patient was doing something to themselves?

This recent case report in the December issue of the Journal of Plastic, Reconstructive & Aesthetic Surgery prompted me to look up the diagnosis of “factitious disorder.”  Here is the abstract summary (full reference below):

This case report presents the history of a 43-year-old man who sustained a relatively minor burn to his face but who subsequently suffered significant morbidity. Although the wound was grafted on a number of occasions, it failed to heal. Multiple investigations were carried out to determine the cause of recurrent wound breakdown. It had been suspected that the patient was interfering with the wound but this could not be proven initially. He was eventually diagnosed with factitious disorder and it was only when this was managed in the multi-disciplinary setting that his wound finally healed.

I don’t have access to the full article, but what I found when I looked up factitious disorder makes me wonder
The Cleveland Clinic has a nice overview of factitious disorder aka Ganser Syndrome aka Munchausen Syndrome (bold emphasis is mine).

Factitious disorders are mental disorders in which a person acts as if he or she has a physical or mental illness when, in fact, he or she has consciously created his or her symptoms. (The name factitious comes from the Latin word for "artificial.")

People with factitious disorders deliberately create or exaggerate symptoms of an illness in several ways.

The Cleveland Clinic website list the possible warning signs of factitious disorders include the following:

• Dramatic but inconsistent medical history
• Unclear symptoms that are not controllable, become more severe, or change once treatment has begun
• Predictable relapses following improvement in the condition
• Extensive knowledge of hospitals and/or medical terminology, as well as the textbook descriptions of illness
• Presence of many surgical scars
• Appearance of new or additional symptoms following negative test results
• Presence of symptoms only when the patient is alone or not being observed
• Willingness or eagerness to have medical tests, operations, or other procedures
• History of seeking treatment at many hospitals, clinics, and doctors’ offices, possibly even in different cities
• Reluctance by the patient to allow health care professionals to meet with or talk to family members, friends, and prior health care provider

I’ll pick on myself here.  In fact that is exactly why a small area in my left eyebrow has failed to heal as quickly as it should.  I keep picking at it, picking off the scab before it’s ready to fall off.  I don’t do it to create or exaggerate the problem.  It’s a nervous tick.  I’ve always been a scab picker (and, yes, I tell my patients not to pick at theirs).  It’s a trait that comes in handy as a surgeon who gets to debride wounds.

Don’t forget that some patients are simply like me.  Don’t forget that some may have a issue like this (Trigeminal Trophic Syndrome).  All these other possibilities must be ruled out before giving the patient the diagnosis of factitious disorder.

REFERENCE

Factitious Disorder as a differential diagnosis for recurrent skin graft failure; D.M. Seoighe, M. Dempsey, C. Lawlor, A.M. O’Dwyer;  
Journal of Plastic, Reconstructive & Aesthetic Surgery - 27 December 2010 (10.1016/j.bjps.2010.11.004)

Factitious Disorder; eMedicine Article, October 22, 2009; Todd S Elwyn, MD and Iqbal Ahmed, MBBS

More on Facial Transplantation

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

There are two related articles from Plastic Surgery Practice by Amy Di Leo who interviewed Daniel Alam, MD on the topic of facial transplantation. Dr. Alam was the primary Microvascular surgeon of the Cleveland Clinic team that performed the 22-hour face transplant procedure. I recommend both to you.

Daniel Alam, MD, on Facial Transplantation: A step-by-step discussion of the historic near-total face transplant in the United States by Amy Di Leo (January 2010)

In Part One of a two-part series of articles, Alam reviews the events that led up to the surgery, including a discussion of donor selection and preparing the patient emotionally for the procedure.

Daniel Alam, MD on Facial Transplantation Recovery and Ethics Issues by Amy Di Leo (February 2010)

Alam: There is a lot of additional recovery for a face transplant patient. That is why it is important for a patient to be local because all the people on the care team need to see her. It wouldn’t make sense for a patient to come to us from Germany for an operation like this. Connie lives about 100 miles away, and she comes for postsurgical visits at least once a month.

Related posts
Face Transplantation – First in the US Done (December 18, 2008)
Cleveland Clinic’s Connie Culp (May 6, 2009)
The Technical and Anatomical Aspects of the World's First Near-Total Human Face and Maxilla Transplant—an Article Review (December 7, 2009)

MDLinx

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

Towards the end of this past year I learned about MDLinx and signed up for the newsletter on Plastic Surgery related articles. I was very impressed this past week to get the “Top Read Articles of 2009.” I noticed many articles of interest which I had not read. Most were in journals I don’t have full access to: Canadian Journal of Plastic Surgery, Australian and New Zealand Journal of Surgery, European Journal of Plastic Surgery, etc.

Here are five that caught my eye:

1. Decreasing expander breast infection: A new drain care protocol; The Canadian Journal of Plastic Surgery, Spring 2009, Volume 17 Issue 1: 17-21; JD Murray, ET Elwood, GE Jones, R Barrick, J Feng

2. A new validated otoplasty dressing technique; Eur J Plast Surg (2009) 32:119–121; Mohammad Mehdi Samim & David Mather & Sharif Al-Ghazal

3. The treatment of dermal scars by three-dimensional Z-plasty; Eur J Plast Surg (2009) 32:221–222; Bin Xu & Pengcheng Jiang & Bing Wang

4. Surgical Treatment of Rhinophyma; Advances in Dermatology and Allergology, 2009, XXVI, 3: 126-133; Edward Lewandowicz, Henry Witmanowski, Daria Sobiesze

5. The Oncological Safety of Skin Sparing Mastectomy with Conservation of the Nipple–Areola Complex and Autologous Reconstruction: An Extended Follow–Up Study; Annals of Surgery, March 2009 - Volume 249 - Issue 3 - pp 461-468; Gerber, Bernd MD, PhD; Krause, Annette MD; Dieterich, Max MD; Kundt, Günther PhD,†; Reimer, Toralf MD, Ph

MDLinx is a medical news and information source, free with registration. It reviews 1200 medical journals daily. The articles are indexed by 35 specialties and 845 subspecialties. I am finding it to be a nice source of information.