Spinal Accessary Nerve Injury

Updated 3/2017--all links removed as many no longer active. 

This injury will never result in an individual qualifying for SSI disability.  Not even when it occurs on the side of  your dominant hand.  That doesn’t mean it isn’t a serious problem and can result in significant shoulder dysfunction and pain.  It simply means it will never “meet” an SSI disability listing and will not result in more than a one-arm light RFC (residual functional capacity) rating. 

The spinal accessary nerve  supplies the sternocleidomastoid (SCM) and trapezius muscles.  So when the nerve is injured your ability to rotate, tilt, flex your head may be impaired (SCM).  Your ability to elevate your shoulder and draw your head back so the face is upward may also be impaired (trapezius muscle involvement).  The shoulder may exhibit a winged scapula which may be more apparent or exaggerated on arm abduction.

Causes of SAN injury include iatrogenic, traumatic, and neurologic. 

Most iatrogenic SAN injury occur following diagnostic lymph node biopsies of the posterior triangle of the neck. Injury rates from these procedures are reportedly 3-8%.   Functional neck dissections are another source of iatrogenic SAN injury.

As with other nerve injuries, if the injury is a transection and is recognized it can be repaired.  This may be done immediately or within 3 to 6 months after the injury. 

If it is uncertain if this nerve was indeed cut or is a closed injury (ie trauma), then close follow-up with serial electrical tests helps determine if surgery will be required. Physical therapy is the mainstay of treatment regardless of whether surgery is indicated. It improves range of motion and encourages a return of strength once contraction occurs.

Nerve regeneration can take 3-12 months, during which time physical therapy is performed. Patients with a spinal accessory nerve injury older than 1-2 years may not be a candidate for nerve surgery.  So the sooner the injury is recognized and diagnosed, the better. Options for these patients may include tendon/muscle transfer techniques to stabilize the scapula and reduce pain.

REFERENCES
1.  Cranial Nerve XI: The Spinal Accessory Nerve – Clinical Methods
2.  Accessory Nerve Injury; Rohan Ramchandra Walvekar, MD, et al; eMedicine, July 20, 2010
3.  Spinal Accessory Nerve Injury; NYU Medical Center

Mindful of Two Breast Implant Scandals

This year began with a breast implant scandal.  This one has brought back memories of the one early in my private practice.

The current one involves the PIP-branded breast implants produced by the French company Poly Implant Prothese and rebranded by the Dutch company Rofil as Rofil M-implants breast implants.  The first one involved silicone implants made by American companies including Dow Corning who no longer makes breast implants.

This picture of 3 implants includes:  top -- an old McGhan double lumen (silicone gel implant surrounded by a saline implant); bottom left – Dow Corning textured silicone implant; and bottom right – Dow Corning smooth silicone implant.  Dow Corning has not made breast implants since approximately 1992.

My post Breast Implants -- Some History (March 3, 2008) covers much of the history of implants in the United States.  Kira Cochrane, The Guardian, wrote about the first patient to receive a breast implant:

It was in 1962 that Timmie Jean Lindsey was offered a solution to a non-existent problem. A factory worker from Texas, ….. And the doctors had another proposal. Had she ever thought about breast implants?

Lindsey had not. ….

……...She's 80 today, still living in Texas, working night shifts in a care home, and those first, experimental globes remain in her chest. ……

I would love to know if they are soft or have become hardened by capsular contractures.  The article doesn’t say.

In the current breast implant scandal, I haven’t noticed anyone urging a class action lawsuit against the French company Poly Implant Prothese or the Dutch company Rofil.  The big issues are 1. do the implants need to be removed or just checked and 2. who will pay for the removal, the government or the private clinics.  The issue isn’t just a European one, it affects women in South American, Mexico, and the United States.

The old scandal in the early 1990s was handled by a class action lawsuit.  I had not been in practice long enough for it to truly affect my then current patients, but I saw many who’s doctors were no longer in practice or non-plastic surgeons who has decided due to the scandal to quit doing breast implants.  I did exams for free, but not the surgeries.  I did, however, not raise prices or take advantage of the situation. 

When I was in practice, I encouraged my breast implant patients to return every year or two for a complimentary breast exam.  This keep us in contact so if anything (ie ALCL and implants, or faulty implants) came up I had current addresses.  I made sure each woman had the information on her implants and encouraged her to keep up with it.  I also encouraged the extended warranty on the implants.  This helps settle who pays for what, at least for the first 10 years.

Women and their doctors need to be mindful that implants are foreign bodies we are placing into the human body.   Women and their doctors should be mindful of future costs that might be incurred from breast implant surgery.   In the United States, many things related to implants, especially those placed for cosmetic reasons only, are not covered by insurance or the extended warranty.

Related posts:
Breast Implants -- Some History (March 3, 2008)
FDA Updates Safety Data for Silicone Breast Implants  (June 23, 2011)
ALCL and Breast Implants  (January 31, 2011)

REFERENCES
1.  Breast implant scandal: now women with Rofil M-implants 'are at risk';  The Telegraph, Matthew Holehouse, January 5, 2012
2.  Breast implants – a brief history of the first 50 years; The Guardian, Kira Cochrane, January 11, 2012
3.  Q&A: PIP breast implant s health scare; BBC Health News, James Gallagher, January 11, 2012
4.  Confusion Reigns Abroad Over Faulty Breast Implants; MedPage Today, Cole Petrochko, January 13, 2012
5.  PIP breast implants: European Commission says reform needed;  BBC Health News, James Gallagher, January 14, 2012
6.  Keeping patients safe: The case for a breast implant registry; The Atlantic,  Anna Yukhananov, January 5, 2012

Cocaine and Ear Necrosis

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

Last week Science Daily had a brief article noting the association of contaminated cocaine with ear necrosis:   Contaminated Cocaine Triggers Decaying, Dying Skin  (photo credit) 

I’ve written about skin complications from drug abuse in the past, but this is not one I knew of.  Most common are skin and soft tissue infections (SSTIs).

The crusty, purplish areas of dead skin (purpura) that can occur with this contaminated cocaine are extremely painful and can open the door to nasty infections.  (note the lower lobe of the ear in the photo)

Apparently the cocaine is contaminated with a de-worming drug commonly used by veterinarians called levamisole,  noted by the U.S. DEA to have been found in 30% of confiscated cocaine in 2008 and 70% in 2009.

This complication from the use of the contaminated cocaine was recently reported in the June issue of the Journal of the American Academy of Dermatology (full reference below).  The report highlights six new and very similar patient cases of purpura, mostly on and around the ears, following the contaminated cocaine use.  There were six cases --  four seen in Rochester, N.Y. and two in Los Angeles. 

Although in each case an extensive battery of blood tests ruled out the usual causes of purpura, the JAAD paper authors write “because testing is not easily performed, we did not test for levamisole in the serum or blood to prove this is the causative agent.”

From the Science Digest article:

According to Mary Gail Mercurio, M.D., an author and associate professor in the Department of Dermatology at the University of Rochester Medical Center, "When we first started seeing these patients they all had a similar clinical picture, but they were really an enigma because they weren't falling into any other pattern we'd seen before. When a colleague at the National Institutes of Health mentioned levamisole contamination, we did toxicity screens and lo-and-behold, all the patients came up positive for cocaine. We had our diagnosis."

Drug enforcement officials have detected levamisole -- which was once used to treat colon cancer -- in cocaine since 2003, but have watched it increase rapidly in recent years. The Drug Enforcement Administration says that the drug, which is inexpensive, is used more and more as a diluting agent in order to stretch supplies. Study authors report that levamisole is known to increase dopamine, a neurotransmitter that helps control the brain's reward and pleasure centers, causing experts to believe it is also added to cocaine to further enhance or prolong the user's high.

Researchers don't know how levamisole causes purpura, which occurs when vessels become plugged and blood can't flow to the skin, leading to skin death and the resulting purplish, crusty appearance. Cocaine alone constricts blood vessels, which is probably the first step, but how levamisole contributes is not yet understood, Mercurio said.

The purpura can occur with both smoking and snorting of the tainted cocaine.  Treatment options include steroids to prevent inflammation, but stopping the exposure to cocaine is the best medicine.

REFERENCES

Characteristic purpura of the ears, vasculitis, and neutropenia–a potential public health epidemic associated with levamisole-adulterated cocaine; Catherine Chung, Paul C. Tumeh, Ron Birnbaum, Belinda H. Tan, Linda Sharp, Erin McCoy, Mary Gail Mercurio, Noah Craft; Journal of the American Academy of Dermatology, 09 June 2011, (10.1016/j.jaad.2010.08.024)

U.S. DEA:  Drugs of Abuse – 2011 Edition

FDA Updates Safety Data for Silicone Breast Implants

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

 

Yesterday, the FDA published this press release:  FDA provides updated safety data on silicone gel-filled breast implants

In November 2006, the FDA approved silicone gel-filled breast implants for breast augmentation in women over age 22 and for breast reconstruction in all women. 

This latest report includes preliminary safety data from post-approval studies conducted by each of the two breast implant manufacturers (Allergan and Mentor), a summary and analysis of adverse events received over the years by the FDA, and a comprehensive review and analysis of recent scientific publications that discuss the safety and effectiveness of silicone gel-filled breast implants.

Based on the report, women should know:

• Breast implants are not lifetime devices. The longer a woman has silicone gel-filled breast implants, the more likely she is to experience complications. One in 5 patients who received implants for breast augmentation will need them removed within 10 years of implantation. For patients who received implants for breast reconstruction, as many as 1 in 2 will require removal 10 years after implantation.
• The most frequently observed complications and outcomes are capsular contracture (hardening of the area around the implant), reoperation (additional surgeries) and implant removal. Other common complications include implant rupture, wrinkling, asymmetry, scarring, pain, and infection. Check out the FDA booklet for patients:  Breast Implants Complications Booklet.
• Preliminary data do not indicate that silicone gel-filled breast implants cause breast cancer, reproductive problems or connective tissue disease, such as rheumatoid arthritis.  However, in order to rule out these and other rare complications, studies would need to enroll more women and be longer than those conducted thus far.

At this time, the FDA is recommending that health care professionals and women who have silicone gel-filled breast implants do the following:

• Follow up. Women should continue to routinely follow up with their health care professionals.  The FDA recommends women with silicone gel-filled breast implants undergo MRI screening for silent implant ruptures at 3 years post-implantation, and every 2 years thereafter.
• Be aware and pay attention to changes. Breast implants are not lifetime devices. Breast implants are associated with significant local complications and outcomes, including capsular contracture, reoperation, removal, and implant rupture. Some women also experience breast pain, wrinkling, asymmetry, scarring and infection.  Women should notify their health care professionals if they develop any unusual symptoms.
• Stay in touch. If a woman has enrolled in a manufacturer-sponsored post-approval study, she should continue to participate. These studies are the best way to collect information about the long-term rates of complications.

Related Posts: 
It’s Happened Again (June 5, 2007)
Breast Implants -- Some History (March 3, 2008)
Silicone vs Saline Breast Implants (March 4, 2008)
Silicone Implants and Health Issues  (March 5, 2008)
Saline or Silicone? (November 18, 2010)
More on Link Between Breast Implants and ALCL (April 25, 2011)

………………………………

Okay, now I want to rant just a bit about some of the headlines I found on this story.  All of these headlines were under the Google news/health section this morning.  I am not fond of misleading or sensationalized headlines, especially when it comes to health news.  This topic is serious to all women who have implants and they don’t deserve to be misled or inappropriately scared.

I did not read each of the following articles.  I am only commenting on my “gut” reaction to their titles.

Examples of headlines I find appalling:

Celebs who should worry about FDA's breast implant alarm (PHOTOS) (International Business Times)

Hollywood celebrities will not keep breast implants for life (Daily Gossip)
FDA: Silicone breast implants have expiration date (The Imperfect Parent) 
Bummer! FDA Says Women Can't Keep Breast Implants for Life (HyperVocal (blog))

Women who are celebrities are no different when it comes to implants than other women.  No implant has a specific expiration date.  Implants are man-made and wear out over time.  A small percentage fail in the first few years, about 20% fail by 10 years, the other 80% last more than 10 years.

The FDA did not say “women can’t keep breast implants for life.”  The FDA did make it clear that no implant currently on the market has a life expectancy equal to the normal life expectancy for a woman.

These headlines I applaud:

FDA: Silicone Implants 'Mostly Safe' and None Last Forever (33 KDAF-TV)
Silicone implants not a lifetime device (UPI.com)
Both are simple with no fear tactics included.

These headlines I find acceptable:
FDA stands by decision to put silicone breast implants back on market (Los Angeles Times)
FDA Says Silicone Breast Implants Are Safe For Women (SmartAboutHealth)
FDA Leaves Silicone Implants on Market Despite Risks (Wall Street Journal)
Breast Implants Basically Safe but Not Lifetime Devices, Say Experts (ABC News)
Breast implants reasonably safe (Washington Post)
Breast implants 'relatively safe' (BBC News)
FDA urges caution for silicone breast implant recipients (Boston Globe)
FDA Sees No New Safety Signals for Silicone Breast Implants (MedPage Today)
Most women with silicone breast implants need more surgery (msnbc.com)
Breast implants safe but not problem-free, FDA says (CBS News)
Silicone Breast Implants Deemed Safe in FDA Side Effects Review (Bloomberg)
Long-Term Complications Likely With Silicone Breast Implants (Medscape)

Impact of Obesity on Breast Surgery Complications – article review

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

Obesity is an ever increasing presence in today’s world.  Thirty-four percent of U.S. adults are now estimated to be obese (BMI>30), up from just 15% three decades ago.

Obesity increases the risk of complications in many medical/surgical situations which has pushed some Ob-Gyns in Florida to refuse to care for pregnant women over a certain weight.

Martin A. Makary, MD and colleagues designed a study to measure the impact on complication rates in obese patients presenting for a set of elective breast procedures.

The PRS journal article referenced below has been published online ahead of print and looks at the impact obesity has on breast surgery complication.

The researchers used claims data from seven Blue Cross and Blue Shield Plans covering individuals with employer-provided coverage and residing in Hawaii, Iowa, Michigan, North Carolina, Pennsylvania, Tennessee, and South Dakota to identify a cohort of obese patients and a non-obese control group who underwent elective breast procedures covered by insurance between 2002-2006.

Criteria for the patient  to be included:
Enrolled in the insurance plan for at least one month before and after surgery

Have a paid claim for breast augmentation, breast reduction, breast lift (mastopexy), or breast reconstruction during the period between 2002-2006

Have either 1) a BMI of 30 kg/m2 or greater, 2) a diagnosis of obesity (using ICD 278.x or V85.x code closest to the date of surgery), or 3) at least one comorbidity associated with obesity (diabetes, hypertension, metabolic syndrome, obstructive sleep apnea, hyperlipidemia, or gallbladder disease) within one year of undergoing the breast procedure

There were 2,403 patients (mean age 42.1 yrs)  in the obese group who were compared to a non-obese control group of 5,597 patients (mean age 48.4 yrs).  Breast reduction was the most commonly performed procedure in the obese and control groups (80.7% vs 63.8%), followed by breast reconstruction (10.3% vs 24.2%), augmentation (4.0% vs 8.9%), and mastopexy with or without augmentation (5.0% vs 3.2%).

Overall, 18.3% of obese patients had a complication compared to only 2.2% in the control group (p<0.001). After adjusting for other variables, the researchers found obesity status increased the odds of experiencing a complication by 11.8 times.

Among the obese patients, at least one complication was observed in 50.5% of patients undergoing breast augmentation (vs. 4.4% of controls), 24.1% undergoing mastopexy (vs. 11.4%), 38.9% mastopexy with augmentation (vs. 5.6%), 29.4% of reconstruction (vs. 1.8%), and 14.6% of breast reduction patients (vs. 1.7%).

The differences between the two groups were most pronounced
in complications such as inflammation (OR=22.2), infection (OR=13.4), pain (OR=11.7), the development of seroma (OR=11.4) and hematoma (OR=10.9).

Obesity status  increased the odds of experiencing a complication (OR = 10.1, adjusted 11.8).  Diabetes (OR = 1.37, adjusted 1.16) and a history of prior chest wall irradiation (adjusted OR = 1.4) were associated with a higher odds of complication.

Hypertension, COPD, a history of neoadjuvant chemotherapy and undergoing a bilateral procedure were not significantly associated with the development of complications.

Makary and colleagues write in their discussion (bold emphasis is mine):

Our data demonstrate that obesity is a major risk factor for complications following elective breast procedures. In light of current trends towards pay-for-performance-based reimbursement, although obesity is currently not accounted for in quality metrics, based on our study, it increases the odds of experiencing any complication within a 30-day postoperative period by 11.8 times. This is in marked contrast to previous studies, which showed either no significant difference in complications between
obese and non-obese patients undergoing elective breast surgery, or just a slight increase.

Although pay-for-performance strives to reward healthcare providers for meeting certain performance measures for quality and efficiency, there is no guarantee that the measures being used accurately reflect the quality of surgical care being provided. For example, the current assumption behind pay-for-performance is that high-quality care reduces surgical
complications.  Our results suggest that variations seen in the rate of complications may be, in part, related to the characteristics of the population--in this case, body habitus. These complications could even occur despite adherence to process measures such as administering appropriate antibiotic prophylaxis. Thus, any measure of quality should consider the effect of obesity on these measures.

REFERENCES
The Impact of Obesity on Breast Surgery Complications; Chen, Catherine L.; Shore, Andrew D.; Johns, Roger; Clark, Jeanne M.; Manahan, Michele; Makary, Martin A.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 9 June 2011; doi: 10.1097/PRS.0b013e3182284c05

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.

Fiorina’s Infection Highlights Reconstruction Complications

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.

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

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

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

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

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

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

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

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

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

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

Related Post:

Infected or Exposed Breast Prosthesis (Sept 1, 2010)

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

REFERENCES

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

Breast Reconstruction Overview; eMedicineHealth

About Breast Reconstruction; Cancer Help UK

Blepharoplasty Complications – an Article Review

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

There is a really nice article in the March 2010 issue of the Journal of Plastic and Reconstructive Surgery which reviews complications of blepharoplasty surgery (full reference below). It is an article worthy of your time if you perform this surgery.

The article divides the complication into time periods which they occur: early (first week), intermediate (1-6 weeks), and late (after 6 weeks). Here is a list of the complications listed and discussed. The information included in my post does not cover all that is covered in the journal article as it is not meant to take the place of the article.

Early Postoperative Period (first week)

Vision Loss

The most feared complication of blepharoplasty is permanent visual loss. The most common cause is retrobulbar hemorrhage, although other causes such as globe perforation, ischemic optic neuropathy, and angle closure glaucoma have been reported.

Retrobulbar Hemorrhage

• Incidence is 0.05%; associated permanent visual loss was diagnosed in 0.0045%. This corresponds to a one in 2000 risk of hemorrhage and a one in 10,000 risk of permanent visual loss.
• Most occur within the first 24 hours after surgery (96%), and of these, more than half occur intraoperatively or within the first 6 postoperative hours.
• The most common presenting symptoms are pain and pressure.
• Treatment should be aggressive for the first 24 to 48 hours postoperatively, as vision has been reported to return in patients with “no light perception” that was present for 24 hours. (photo credit)

Globe Perforation: Inadvertent globe penetration can result from any periocular procedure. Globe perforation is an ophthalmic emergency and necessitates emergent ophthalmic evaluation.

Central Retinal Artery Occlusion Prompt ophthalmic consultation is necessary.

Corneal Abrasion is generally a rapidly reversible cause of decreased vision. The diagnosis is made by patient symptoms (pain, foreign body sensation, light sensitivity) and is usually apparent immediately after surgery.

Dry Eye Corneal irritation is common after blepharoplasty and symptoms are similar to, but less severe than, an abrasion. These symptoms will respond to ocular lubrication and cool compresses.

Eyelid Hematoma usually develop from bleeding orbicularis oculi muscle. Retrobulbar hemorrhage must be ruled out.

Infection, cellulitis or abscess formation, is exceedingly uncommon in the well-vascularized eyelid, but have been reported and can rarely lead to permanent visual loss or cavernous sinus thrombosis.

Eyelid Sloughing due to eyelid necrosis has been reported and can necessitate multiple eyelid reconstructive procedures

Chemosis or conjunctival edema can develop in the early or intermediate postoperative period as the result of incomplete eyelid closure, ocular allergy, or surgical edema with poor lymphatic drainage.

…………………….

Intermediate Postoperative Period (weeks 1 to 6)

Upper Eyelid Malposition

• Ptosis can be seen following upper eyelid blepharoplasty. No statistics are available regarding frequency. Mechanical ptosis can result from postoperative edema or ecchymosis and should resolve with conservative treatment, including cool compresses.
• Lagophthalmos occurs frequently in the postoperative period. Reasons include excessive skin removal, trauma to the orbicularis muscle or peripheral seventh cranial nerve, tethering of the eyelids by sutures or Steri-Strips, and postoperative pain, leading to guarding and incomplete closure. It is usually temporary. Lubrication and lid massage are advisable in the intermediate postoperative period.

Lower Eyelid Malposition is the most commonly reported complication after lower eyelid blepharoplasty. It may range from mild inferior scleral show to severe cicatricial ectropion in 1%. (photo credit)

Corneal Exposure

As in the early postoperative period, keratopathy may persist or become evident during the intermediate period. First-line treatment is expectant, with frequent ocular lubrication and taping. One condition worth mentioning is the patient with undiagnosed thyroid ophthalmopathy who undergoes blepharoplasty that unmasks lid retraction and keratopathy.

Lacrimal System Dysfunction Epiphora can result secondary to dry eye, exposure keratopathy, or an impaired lacrimal pump. Dysfunction usually returns to normal, but extended tearing requires further evaluation for punctal malposition or canalicular damage.

Strabismus and Extraocular Muscle Disorder Diplopia is a rare but potentially disabling complication of blepharoplasty.

Signs that make diplopia less worrisome are preoperative history of strabismus, monocular diplopia that clears with blinking (suggestive of precorneal tear film abnormality), and intermittence.

Persistent binocular diplopia requires additional consideration. In a review of over 900 blepharoplasty procedures, the risk of persistent strabismus was approximately 0.2 percent.

…………………………………….

Late Postoperative Period (after 6 weeks)

Upper Eyelid Malposition

Ptosis If the ptosis was not present preoperatively, then it may be the result of direct trauma to the levator aponeurosis or secondary attenuation from postoperative edema or hematoma. If secondary attenuation has occurred, additional surgery should be delayed until 3 months postoperatively.

Upper Eyelid Retraction and Lagophthalmos

Lagophthalmos in the late postoperative period is the result of excessive skin excision or incorporation of the orbital septum in skin closure resulting in eyelid retraction. If conservative therapy fails or severe exposure keratopathy warrants, surgical correction should be considered.

Lower Eyelid Malposition

Late lower eyelid malposition is complex and requires careful consideration based on anatomical concepts. Identification of the affected lamella (anterior, middle, or posterior), usually the result of deficient tissue or cicatrization, is the key to successful reconstruction. In addition, horizontal laxity must be considered as a potential component of malposition. …………..

Malar Festoons are more likely to occur in patients who are predisposed to fluid accumulations (ie history of thyroid disease, renal failure, sinusitis, allergies). (photo credit)

Patients who are at higher risk should be treated intraoperatively with intravenous steroids. Postoperative oral steroids are useful. Furosemide (Lasix, 20 to 40 mg daily) early in the postoperative course is helpful. Although persistent malar festoons can be excised, the success rate is low. If the underlying condition is systemic, eyelid surgery cannot locally correct the problem.

Dry Eye Syndrome

True dry eye disease in a postblepharoplasty patient can only be diagnosed after ample time has been allowed for resolution of common early and intermediate sicca symptoms. …...

Initial treatment of dry eye consists of ocular lubrication. Treatment failure should prompt ophthalmologic examination, with consideration of antiinflammatory eyedrops (such as topical cyclosporine) or punctal occlusion.

REFERENCES

Blepharoplasty Complications; Lelli, Gary J. Jr; Lisman, Richard D.; Plastic and Reconstructive Surgery. 125(3):1007-1017, March 2010; doi: 10.1097/PRS.0b013e3181ce17e8

Minor Complications after Blepharoplasty: Dry Eyes, Chemosis, Granulomas, Ptosis, and Scleral Show; Pacella, Salvatore J.; Codner, Mark A.; Plastic and Reconstructive Surgery. 125(2):709-718, February 2010; doi: 10.1097/PRS.0b013e3181c830c7

Acute Hematoma Seven Years Postop – an Article Review

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

There is a unique case presented in the Canadian Journal of Plastic Surgery of an acute, symptomatic hematoma occurring 7 years postoperatively.  Most unique is the well defined mechanism of injury which caused the hematoma.

For background, the article reminds us that hematoma formation is a complication of augmentation mammoplasty whether for cosmetic or reconstructive purposes.  Most of these will occur in the immediate postoperative period.  The incidence is reported to range from 2-10.3% in this immediate postoperative period.

In their review of the literature, the authors found only 20 cases reported to have occurred in the late postoperative period.  Most of these cases did not have a definitive mechanism of injury or develop symptoms immediately after the triggering event.

In contrast, their patient presented with both a known and traceable cause of her bleed and with symptoms that developed immediately after the initial event.

The patient was a 53 year old female who had undergone a right mastectomy with reconstruction using a saline implant seven years previous to this injury. 

The patient reported having right breast soreness after performing vigorous stretching exercises.  The following morning, she noted increased pain and bruising over the medial aspect of the breast.  She underwent right breast ultrasound in the clinic that demonstrated a small fluid collection between the anterior surface of the implant and the overlying tissue, which was of unclear consistency…..A magnetic resonance imaging scan confirmed both intracapsular and extracapsular hemorrhage.

The patient was taken to the operating room; on entering the capsule, a pool of dark red blood was visualized and 200 ml of clot was removed…..

Interesting case review.


REFERENCE
Acute symptomatic hematoma with defined etiology seven years after breast reconstruction: A case report and literature review;
Canadian Journal of Plastic Surgery, Summer 2010, Volume 18 Issue 2: e 27-e 29; AK Seth, JY Kim

Late Hematoma after Augmentation Mammaplasty Apparently Due to Myoelectrostimulation; Cagli, Barbara; Vulcano, Ettore; Marangi, Giovanni Francesco; Cogliandro, Annalisa; Persichetti, Paolo; Plastic and Reconstructive Surgery. 119(1):439-440, January 2007; doi: 10.1097/01.prs.0000233618.94269.d4

Local Complications after Cosmetic Breast Augmentation: Results from the Danish Registry for Plastic Surgery of the Breast; Hvilsom, Gitte B.; Hölmich, Lisbet R.; Henriksen, Trine F.; Lipworth, Loren; McLaughlin, Joseph K.; Friis, Søren; Plastic and Reconstructive Surgery. 124(3):919-925, September 2009; doi: 10.1097/PRS.0b013e3181b0389e

Shout Outs

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

Dr V, 33 Charts, is the host for this week’s Grand Rounds.   It’s the “Artsy Doctors, Genes and Creepy Imagery” edition.  You can read this week’s edition here.

It’s been a tough week for the anti-vaccine movement but an important week for pediatric health. Yesterday the UK’s General Medical Council announced that Andrew Wakefield, who’s fraudulent manipulation of data spawned the vaccine-autism cottage industry, would be ‘struck’ from the medical register. This action by the GMC is one more nail in the coffin of the man who has singlehandedly turned back the clock on two generations of pediatric public health. Check out Respectful Insolence for some pithy commentary and a pointed, must see interview with Matt Lauer. This issue finally seems to be circling the drain………

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Dr Lisa is in Haiti and has been blogging her experience. I hope you will check it out. You can begin with her first post from there, First Haiti Thoughts

Landing in Port Au Prince, my first glimpses of Haiti revealed a lush Caribbean island like so many others. The large central mountains, relics of the islands volcanic origin, the rocky coastline, the lush vegetation, then we landed and we were shuttled to the boarding terminal. Damage from the earthquake was still visible in the buildings at the airport. Then we left the airport grounds, and on our short drive, the disarray of the city was obvious. Although despite the extant destruction there were many signs of regrowth.

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Check out this Daily Beast article by Ayaan Hirsi Ali:  Why Are American Doctors Mutilating Girls? 

The American Academy of Pediatrics recently put forward a proposal on female genital mutilation. They would like that American doctors be given permission to perform a ceremonial pinprick or “nick” on girls born into communities that practice female genital mutilation.

Female circumcision is a custom in many African and Asian countries whereby the genitals of a girl child are cut. There are roughly four procedures. First there is the ritual pinprick. This is what Pediatrics refers to as the “nick” option………..

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Tony Brayer  was interviewed by My Life Stages about her experience as a patient:  Enough is Enough -- When Knee Pain Hits the Tipping Point  (photo credit)

…………Not long after that, she scheduled her surgery for the 2009 Christmas holiday. Now recovering from a total replacement of her right knee, she recently talked about her experience as a doctor, patient and woman.

What was the moment at which you knew you needed to have knee replacement surgery?
I never considered that this was something I would be facing. I was in denial. I would try to hide it. I didn’t want anyone to see me limping, and I was surprised when people noticed that something was wrong. I had a lot of pain that I just pushed through. But one day I was getting ready for work and out of the blue, I just burst into tears and said, ‘I just can’t do this anymore. I am really crippled.’ That was my wake up call……….

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As we head into summer you may want to check out the Environmental Working Group’s list of the best and worst sunscreens can be found on their  searchable database.  A few of the best rated include:  Al Terrain Aquasport Performance SPF 30, Badger Sunscreen for Body and Face SPF 30, California Baby Sunscreen SPF 30, and Vanicream Sunscreen Sport SPF 35.

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Dr Wes has done a review of a film I wish all of us could see: The Vanishing Oath: A Review.  He now has reported that the Chicago premiere was a success.

I would like to take a moment to thank the over 120 people who took time out from their busy schedules to attend the Chicago premiere of The Vanishing Oath at the Wilmette Theatre last evening. For many, it was the first time people they were exposed to the challenges that confront physicians daily in our current health care system…..

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Medical Industry News linked to this article by Diane Suchetka:  Burn victim hopes her story calls attention to dangers of surgical fires.  The article includes before and after burn photos.

There are two Lauren Wargos.

One is so beautiful, you can't stop looking at her. The other was so disfigured, you had to look away.

One wants to remember. The other to forget.

One would rather not talk about what happened. The other wants the whole world to know.

Months after the surgery, Lauren Wargo's one eye would still not close all the way, she had trouble reading and her face was scarred.

It's that last Lauren Wargo who's stepping up now, four years after her face was burned during surgery to have a mole removed from her eyebrow. She's doing it, she says, because she wants to make sure what happened to her doesn't happen to anyone else. ……

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Medgadget is sponsoring the The 2010 My Medical Museum Competition along with Dr. Allen Roberts, aka GruntDoc.

This contest is an opportunity to showcase your medical museum's treasures, as well as to document your local medical history and explain how clinicians and scientists in your area contributed to medicine. So, make a presentation and tell everyone a fascinating story.

To get everyone on equal footing, we've implemented a dynamic publishing platform where you create an online presentation. The My Medical Museum website will let you upload pictures, file reports, embed videos, and make a presentation that will impress the judges. Collaboration is fine, too -- form a group and grant access so your teammates can contribute.

The Grand Prize is a brand-new Wi-Fi 32GB Apple iPad, no less.

So, what else are you waiting for? Gather your friends, family or fellow medical geeks and head over to explore your local medical museum. Develop your presentation and finalize it by Sunday, June 13, 2010.

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It’s time again for the web-based quilt festival hosted by Amy – Blogger’s Quilt Festival, Spring 2010.  I submitted my “First Quilt” as part of the festival.  There is a long list of blogging quilters who are participating.  Grab a cup of coffee or tea and have fun checking them all out.

Welcome to the third Blogger's Quilt Festival!  I'm so glad that you are here - and I hope that you plan to enter a quilt in the Festival!  Everyone is welcome to participate, this is a relaxed festival with no judging, no gloves, and beverages are allowed, encouraged even!  :)

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Dr Anonymous’ BTR show guest this week will be Dr. Jay Lee, Family Physician & Health Policy Expert. The show begins at 9 pm ET.

Upcoming shows (9pm ET)

6/3: Dr. Deb Clements, Family Physician who recently was in Haiti
6/10: Ray Saputelli, NJ Academy of Family Physician

Capsular Contracture

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

Capsular contracture is a complication of breast implants of all types:  saline, silicone, smooth, textured, etc. 

When the implant is placed, the body forms a capsule of fibrous material around it as it would for any foreign body (ie pace maker, breast implant, etc).  The capsule is initially thin and soft, with little or no effect on the appearance of the breast.  If it remains that way, then it is not called a contracture.

Capsular contracture occurs when the scar tissue or capsule that normally forms around the implant tightens and squeezes the implant. It can happen to one or both of the implants. There are four grades of capsular contracture known as Baker grades.

The Baker grading is as follows
Grade I
breast is normally soft and looks natural
Grade II
breast is a little firm but looks normal
Grade III
breast is firm and looks abnormal
Grade IV
breast is hard, painful, and looks abnormal
Capsular contracture may require reoperation, usually for Grades III and IV, and it may occur again.

The first article listed below looks at the current literature relating to this complication of breast implant surgery, focusing particularly on occurrence rates, risk factors, cause, and treatment modalities to provide the plastic surgeon with an up-to-date review of the current available evidence.

The authors did a literature search of the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases using three groups of key words --the first relating to the organ involved (breast), the second relating to the surgical procedure performed and related technical issues, and the third relating to the surgical complications. Potentially relevant articles were identified by means of the title and the abstract, and full articles were obtained and assessed in detail.

The authors note:  “Only a few studies have included large enough sample sizes, were conducted in a prospective manner, were adequately randomized, and achieved adequate follow-up periods to obtain a true measure of rates of capsular contraction occurrence.”

Reported rates of capsular contractures vary widely, ranging from 1.3 to 30 percent of patients who receive implants.

The longer the implants were in place, the greater the cumulative risk of developing contracture, which would suggest a direct correlation between when the implant is placed and the time to developing contractures.

Approximately 92 percent of contractures occur within the first 12 months following surgery.

A number of parameters seem to influence the occurrence of contractures, including the indications for surgery (breast reconstructions versus cosmetic augmentations), type of prosthesis used (smooth versus textured and saline versus silicone), and positioning of the implant (subglandular versus submuscular).

Currently, Mentor lists the rate of capsular contracture in their patient information brochures (cosmetic not reconstructive) as 9% (Grade III – IV), but note the literature has a wide range of 1.3% to 30%.

Women having reconstructive rather than aesthetic (or cosmetic) augmentation have a higher risk of developing capsular contracture.

Radiotherapy increases the incidence of capsular contractures. Unfortunately, most studies are retrospective in nature and analyze groups of patients who received radiotherapy at variable time points (before, during, or after reconstruction), concomitant chemotherapy, implant positioning or type, and type of contractures reported (only Baker grade 3 or 4 versus all contractures).  All of these factors may partly explain the wide range of reported contractures in the irradiated groups (32- 73%) versus non-irradiated groups (0- 40%).

Numerous studies have looked at shell characteristics (smooth vs textured surface) in regards to contracture rate and tend to find textured surfaces produced a lower incidence of contractures when compared with smooth ones.  

In the first meta-analysis, Barnsley et al. proved the protective effect of textured implants over smooth surfaces (relative risk, 0.19; 95 percent confidence interval, 0.07 to 0.52), with smooth implants showing a five-times greater risk of contracture formation. 

In the second meta-analysis, 235 patients were analyzed, and textured implants were shown to produce fewer capsular contractures when compared with smooth implants at 1 year (relative risk, 4.2; 95 percent confidence interval, 1.6 to 11.0), 3 years (relative risk, 7.3; 95 percent confidence interval, 2.4 to 21.7), and 7 years of follow-up (relative risk, 3.0; 95 percent confidence interval, 0.9 to 10.4).

Only one study showed no significant differences between smooth versus textured implants for the occurrence of capsular contractures.  However, this trial had a Jadad score of 2, indicating a poor methodologic quality with a high degree of variance in the results.

Partial or complete submuscular placement and subfascial positioning are  association with lower rates of capsular contractures.  Many of the articles mentioned are either small or retrospective.

Seckel and Costas retrospectively studied 76 patients (146 breasts) who had undergone partial or total submuscular breast cosmetic augmentation.  No difference was observed between the total and the partial musculofascial coverage for the occurrence of capsular contractures [zero of 35 (0 percent) versus one of 41 (0.02 percent); Fisher's exact test, p = not significant].

Hendricks reviewed 650 patients who had received textured silicone gel implants beneath the pectoralis major muscle, the external oblique muscle, the rectus sheath, and the serratus anterior muscle fascia.  In this study, no cases of Baker grade 3 or 4 capsular contractures were reported.

Ventura and Marcello retrospectively analyzed 100 patients who had received primary breast enlargement with textured implants positioned in the subfascial compartment and found that only two patients (2 percent) experienced Baker grade 2 capsular contractures.

Finally, in a retrospective multicenter study of more than 500 patients, Gutowski et al. found that the use of subglandular positioning of the prosthesis increased the risk of capsular contractures by almost eight times.

It is a nice review of the literature which points out the short comings of our knowledge.

Although it is apparent from the articles studied in this review that a great deal of progress has been made over the past few decades toward elucidating the etiopathogenesis of capsular contractures, the exact nature and contribution of molecular, immunologic, and microbiological factors remain unclear.

Only a few studies have included large enough sample sizes, were conducted in a prospective manner, were adequately randomized, and achieved adequate follow-up periods to obtain a true measure of the rates of capsular contracture occurrence.

Therefore, there is a scant and often inconclusive body of evidence relating to this complication. For example, the contribution of chemotherapy to the occurrence of capsular contractures warrants more thorough investigation.

Likewise, the possibility of preventing this complication by use of experimental drugs needs to be looked at more closely.

Revision surgery remains the only effective treatment option available to us at this time but is limited by its high associated risk of recurrences and complications (hematoma or pneumothorax) when the implant is originally placed in the submuscular position. It is hoped that future studies will focus on attempting to resolve some of the issues highlighted in this review.

REFERENCE

Capsular Contractures: A Systematic Review; Plastic and Reconstructive Surgery. 124(6):1808-1819, December 2009; Araco, Antonino; Caruso, Riccardo; Araco, Francesco; Overton, John; Gravante, Gianpiero

FDA Breast Implant Info, May 2009

Double-Bubble Breast Deformity

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.

Recently a Staten Island woman was awarded $3.5 million after developing a double-bubble breast deformity after a breast augmentation/mastopexy surgery.

I don’t know if the award was warranted, but I do know that the deformity is a known risk of breast augmentation surgery. I try very hard to tell patients about possible risks of surgery, but none of us go into surgery thinking we will be the half or one or two percent.

As the surgeon, I take pride in my work and give the best I can. It is never my intention for a patient to have a poor result. It is not good for them or for me.

So let’s talk a minute about double-bubble deformities. What is it? In a double bubble deformity the implants are usually positioned too superiorly under the muscle (first bubble) with an overhang of skin/breast tissue drooping lower (second bubble). (photo credit)

Patients with significant postpartum atrophy, glandular ptosis, and significant native tissue volume are at a higher risk for developing a double-bubble deformity.

In patients with the above, it is best to consider placing the implant in the subglandular position rather than the submuscular. It is also important to consider doing the mastopexy first and the implantation procedure at a different surgery in the future.

Another important consideration is doing the proper lift procedure so that enough skin is removed. This may mean the patient has to accept more scars (ie an anchor scar rather than inferior vertical scar, or an inferior vertical scar rather than a periareolar scar).

Once the deformity has developed, then correction may require capsule work, repositioning the implant, revising the mastopexy (or adding one).

REFERENCES

Breast Augmentation; Plastic and Reconstructive Surgery. 114(5):73e-81e, October 2004; Spear, Scott L.; Bulan, Erwin J.; Venturi, Mark L.

Breast Augmentation: Choosing the Optimal Incision, Implant, and Pocket Plane; Plastic and Reconstructive Surgery. 105(6):2202-2216, May 2000; Hidalgo, David A.

Shaping the Breast in Aesthetic and Reconstructive Breast Surgery: An Easy Three-Step Principle. Part IV-Aesthetic Breast Surgery; Plastic and Reconstructive Surgery. 124(2):372-382, August 2009; Blondeel, Phillip N.; Hijjawi, John; Depypere, Herman; Roche, Nathalie; Van Landuyt, Koenraad

Breast Asymmetry; Aesthetic Surgery Journal, Nov 2003 (Vol. 23, Issue 6, Pages 472-479); Daniel C Morello, Marie Christensen, David A Hidalgo, Scott L Spear

Treatment of Breast Ptosis; Aesthetic Surgery Journal, July 2003 (Vol. 23, Issue 4, Pages 279-285); Stephen R Colen, Sharon Y Giese, Ruth Graf, Dennis C Hammond

Symmastia After Augmentation Mammoplasty

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

Symmastia (also known as synmastia) is a condition that occurs when breast implants sit too close to the middle of the patient’s chest.  Extreme cases can even lead to the “uniboob” look. Fortunately, it is a rare complication of augmentation mammoplasty surgery. 

Developmental symmastia can occur without prior surgery in patients who have breast hypertrophy and an aberrant soft-tissue connection across the midline.

Dr Spear (4th reference article below) noted (bold highlight is mine):

Based on our experience with postaugmentation synmastia, a number of facts have emerged. All of the implants were subpectoral. The majority of these women had undergone more than one operation. Many of them had undergone successive operations to enlarge the size of their implants and breasts. Many of them had large implants, arbitrarily defined by us as greater than 400 cc or with a diameter of 14 cm or more. Several of the patients had associated chest wall skeletal deformities, and some had undergone simultaneous mastopexy at the time of their breast enlargement.

Prevention of symmastia is much better than having to try to fix it.   Care must be taken in dissection of the pocket, especially medially.  It is preferable to use implants that “fit the body.”  By this I mean, implants should not be wider than the available hemithorax of the individual patient.  Try to get the patient to use a smaller implant or perhaps a high profile with a smaller base width.  Avoid excessive detachment of the pectoralis muscle’s medial sternal attachments. 

Correction of symmastia requires restoration of the presternal subcutaneous integrity and medial closure of the pocket.   Techniques to achieve this include capsulorrhaphy, capsular flaps, AlloDerm or other materials, adjustable implants, explantation with delayed reimplantation, and change to a subglandular pocket.  All have drawbacks in terms of reliability, technical difficulty, and convenience.

 

REFERENCES

1.  Symmastia: The Problem of Medial Confluence of the Breasts;  Plast & Reconstr Surg 73(2):261-266, February 1984; Spence, Robert J.; Feldman, Joel J.; Ryan, James J.

2.  Surgical Reconstruction of Iatrogenic Symmastia; Plas & Recontr Surg 121(3):143e-144e, March 2008; Foustanos, Andreas; Zavrides, Harris

3.   The "Neosubpectoral" Pocket for the Correction of Symmastia; Plast & Reconstr Surg 124(3):695-703, September 2009; Spear, Scott L.; Dayan, Joseph H.; Bogue, David; Clemens, Mark W.; Newman, Michael; Teitelbaum, Steven; Maxwell, G Patrick

4.   Synmastia after Breast Augmentation; Plas & Reconstr Surg 118(7S):168S-171S, December 2006; Spear, Scott L.; Bogue, David P.; Thomassen, John M.

5.   Correcting Symmastia; Steven Teitelbaum, MD, FACS Website (nice photos)

6.   Correction of Symmastia After Augmentation; Thomas M. DeWire, Sr., MD, FACS Website  (nice photos)
7.   YouTube Video of Symmastia Repair
8.    My Breast Augmentation & Chin Revision (YouTube Video)

Peristomal Skin Complications and Management -- an Article Review

 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.

There is a very nice review article in the “throw away” journal Advances in Skin & Wound Care (full reference below) which discusses the causes and management of peristomal skin complications.  The photo (credit) to the right shows normal, healthy skin around a stoma.

Peristomal complications are one of the most challenging aspects of living with ostomies.  The purpose of this review article was stated to be “to illustrate practical approaches to prevent and treat common peristomal skin conditions.”

The authors propose the use of the mnemonic MINDS to help clinicians remember and be mindful of the potential
causes of peristomal skin problems:

M:  Mechanical trauma from the ostomy equipment and skin stripping
I:     Infection (bacterial and fungal)
N:  Noxious chemical and irritants including strong alkaline, feces, or urine
D:   Diseases of the skin that are common in persons with ostomies, such as pyoderma gangrenosum, psoriasis, and so on
S:    Skin allergens

The article then proceeds to address each of those with suggestions for each.

There is a nice table of sealants/protectants which can be used to minimize skin stripping (mechanical) due to loss of epithelial cells with repeated application and removal of adhesive tapes and appliances.  The photo (credit) to the right show a severe case of contact dermatitis surrounding a stoma.

Silicones are polymers that include silicone together with carbon, hydrogen, oxygen.  These are applied to the peristomal skin.
Zinc oxide powder is an inorganic compound that is insoluble in water.  It is applied generously to skin.  It ma interfere with activity of ionic silver.
Acrylates form a protective interface on skin attachment sites.  They are sprayed or wiped on skin sparingly.  Allergy is uncommon.
Hydrocolloid wafers consists of a backing with carboxymethylcellulose as the filler, water-absorptive components, such as gelatin and pectin (commercial gelatin desserts), and an adhesive.  Window frame the stoma to prevent recurrent stripping of skin.  Allergies have been reported from some colophony-related adhesives that are associated with some hydrocolloid dressings

The article addresses another mechanical issue, urostomy encrustations, which affect about 20% of people with a urostomy.  These encrustations are precipitation or crystals of phosphates and uric acid caused by accumulation (stagnation) of urine, alkaline urine, and infection.

These reddish-brown and gritty deposits produce a localized inflammatory change that resembles the wart virus clinically and is referred to as false wartlike lesions (pseudoverrucous lesions [Figure 2]) or
pseudoepitheliomatous hyperplasia.

Other signs and symptoms may include localized pain, erythema, or a loss of the superficial epidermis, with the remaining epidermis forming the base (erosion).

This condition is mainly caused by improper skin barrier/pouch with an opening that is too large for the stoma, leading to urine leakage around the peristomal
skin.

Treatment is directed at the specific problem as outlined in Table 3. Other strategies may entail the use of a urostomy pouch that has a 1-way valve to prevent retrograde flow of urine, a convex pouching system for uneven peristomal skin or recessed stomas, and proper sizing of skin barrier and pouch, so peristomal skin is not chronically overexposed to effluent.

If you take care of patients with osteomies, then check out the article for their discussion of the other causes.  An osteomy expert may not find it informative, but for the rest of us its is.  The article includes some nice photos which illustrate the different problems.

For all you general surgery residents, check out this  video of a preoperative stoma marking done by Sterile Eye.  Proper placement of a stoma can alleviate a lot of problems.

REFERENCE

Peristomal Skin Complications and Management; Advances in Skin & Wound Care. 22(11):522-532, November 2009 [doi: 10.1097/01.ASW.0000305497.15768.cb]; Woo, Kevin Y.; Sibbald, R. Gary; Ayello, Elizabeth A.; Coutts, Patricia M.; Garde, Dianne E. 

Reducing the Incidence of Ear Deformity in FaceLift – an Article Review

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.

This article by Dr Daniel Man (full reference below) is well worth the time spent reading it.  Telltale signs of facelift procedures can include tightening across the lower face, visible scars, a distorted hairline, and the “pixie ear” deformity.   Dr Man looks at the causes of the ear deformity and ways to prevent it. (photo credit)

Dr. Man has provided a pdf file of the article on his website, so you don’t have access to the Aesthetic Surgery Journal to read the article.

Between January 2005 and November 2007, the author performed facelifts on 106 patients using a technique that included autologous fat injections to improve facial volume, hidden incisions in and around the ear, and absorbable bidirectional barbed sutures. Patient charts and photographs were reviewed retrospectively.

Pre- and postoperative angles were measured with respect to the ear and face and were documented to determine the degree of improvement or deformity.

Results: Significant improvement of the specified angles was noted in 70% of cases following facelift surgery; in these cases, the ear position was elevated. No change in ear position occurred in 10% of cases. Some distortion and lowering of the ear was seen in the remaining cases.

There are nice photos included in the article.  He writes clearly about his technique. 


REFERENCE
Reducing the Incidence of Ear Deformity in Facelift; Aesthetic Surgery Journal Vol 29 (4) 2009, pp 264–271; Daniel Man, MD
Dr. Yang Explains... Pixie Ears; November 2007 (good information here, too)