Shout Outs

Updated 3/2017--photos and all links removed as many no longer active. 

Paul Ware, Life with Huntington's, is (suppose to be) the host for this week’s Grand Rounds. You can read this week’s edition here.

Next week’s host is Dr. Rob (@doc_rob): What’s Grand and Round and Comes in an RSS Feed?

……To submit your GR post for next week’s GR, fill out the attached submission form. I must have submissions in before Sunday, March 4th at 6 PM EST……

………………………………….

H/T to @jilltomlinson who asks.

Was this 27yo man's life lost in ill-conceived race to perform "World 1st" surgery? bit.ly/x2bGEJ #retrospectoscope

The link is to this Mai lOnline article: Man, 27, who had world's first quadruple limb transplant dies days after operation.

A 27-year-old Turkish man who underwent the world's first would-be quadruple limb transplant died yesterday, hours after the limbs were removed due to metabolic failure, the hospital said…….

I thought it was too risky when I first heard about the transplant prior to them having to later remove the limbs. We are certainly pushing the limits with transplants these days with double hand, face, multiple organ, etc.

………………………………………..

From Letters of Notes a letter that gives a glimpse of breast Cancer in 1855. This woman had surgery with no pain meds: 'Deep Sickness Seized Me"

In September of 1855, Lucy Thurston — a 60-year-old missionary who had been living in Hawaii with her husband since 1820 — underwent a mastectomy after being diagnosed with breast cancer. Incredibly, she somehow endured the operation wide-awake, without any form of anaesthetic. She wrote the following letter to her daughter a month later and described the unimaginably harrowing experience.

The procedure was a success. Lucy Thurston lived for another 21 years………………

…………………………………….

From @Skepticscalpel comes a post with his take on the survey in the Archives of Surgery: Surgeons and alcohol abuse.

“Prevalence of alcohol use disorders among American surgeons” appeared in the February, 2012 issue of Archives of Surgery.

A survey of 7197 surgeons, all members of the American College of Surgeons [ACS], had a 28.7% response rate and revealed that 15.4% had scores on an alcohol use assessment test that indicated abuse of or dependence on alcohol. This is consistent with the rate of such alcohol problems in the general public…………….

………………………………………

VIDEO: Kyle Dyer, 9NEWS anchor, interviews with the Denver Post

Channel 9 news morning anchor Kyle Dyer talked to the Denver Post on Wednesday, February 23, 2012, about the injuries she sustained from a dog bite and her road to recovery.……. Video by Mahala Gaylord

……………………………..

H/T to @impactednurse ‏for this tweet:  “Very cool. Federico Carbajal's anatomical sculptures made with galvanized wire: bit.ly/yRSvFk”

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

More Surgeon’s Caps

These are caps I made between just before Christmas and the first part of January. 

The first ones went to @doctorwes after he made his request for photos of Christmas themed clothing seen at work. 

I then decided I needed to use some of this lovely fabric from Africa given to me by an old high school friend to make @Bongi1  and @globalsurgeon surgeon’s caps.  I gave bongi his choice and he chose the colorful ones.  No photo of him wearing his, but received this nice tweet.

@globalsurgeon did share a photo of @ReinouGroen via twitter wearing one of his (theirs):   yfrog.com/kk54exnj

These two went to @bramzo after he made an innocent comment in regards to @Bongi1 receiving his.


I have shared my pattern via google docs (pdf file).
Related Posts:
Surgeon’s Caps  (April 18, 2009)
Razorback Surgeon's Caps for a Colleague (Oct 17, 2010)

Body Contouring Not Common After Bariatric Surgery

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

A study on this topic was presented at the recent American Society of Plastic Surgeons (ASPS) annual conference in Denver.   The article is also in the October issue of the Plastic and Reconstructive Surgery journal (reference #2 below).

The article notes that more than 220,000 bariatric procedures are done annually in the United States.  This number (IMHO) is likely to increase as these procedures have become an major tool in the treatment of obesity which now affects a third of adults in this country.

Massive weight loss, regardless of whether by bariatric procedure or by diet/exercise, will often leave the individual with excess skin.  This excess skin can be both a cosmetic and functional issue for the individual.

Jason Spector, MD and colleagues designed their study to “explore demographic features and patient education regarding body contouring procedures in the bariatric surgery population.”

Their study consisted of a survey mailed to 1,158 patients who underwent bariatric surgery between 2003 and 2011. Two hundred eighty-four patients responded (24.5%). 

Of the responders, 97.2% had their bariatric procedure covered by insurance.  Only 72 of the responders (25.4%) reported having discussed body contouring surgery with their bariatric surgeon.  Only 40 (14.1%) were referred for a plastic surgery consultation.

Only 33 (11.6%) actually had body contouring procedures done at the time of the survey.  The article does not mention what percentage of these procedures were covered by insurance verse considered self-pay.  I have found it infrequent that insurance will actually pay for removal of excess skin resulting from massive weight loss after a bariatric procedure.  It is a battle to prove the health issues (rashes, skin infections, mobility/comfort issues depending on where the excess skin is located, etc).

The article does note that the most frequent reasons cited for not undergoing body contouring surgery were expense (29.2%) and lack of awareness (23.6%). 

Body contouring after massive weight loss is a mixture of cosmetic and non-cosmetic.  Sometimes it is clearly one or the other, more often it is a combination. 

Spector states (in the press release), "Many massive weight loss patients suffer large amounts of loose, sagging skin as a result of their rapid weight loss that, if not removed, can cause rashes, wounds, infection, and limit comfortable mobility.  It is apparent that insufficient counseling at the time of bariatric surgery is obscuring viable body contouring options for these patients."

Yes, counseling is important, but if the individual can not afford it and insurance doesn’t cover it then the percentage of patients having the body contouring procedures isn’t likely to change.

REFERENCES

Many Would Remove Loose Skin if Informed of Options, Insurance Covered Procedures, Study Reveals; ASPRS press release, 09/21/2011

Body-Contouring Following Bariatric Surgery: How Much Is Being Done?; Reiffel, Alyssa J.; Jimenez, Natalia; Millet, Yoann H.; Dent, Briar L.; Lekic, Nikola; Burrell, Whitney A.; Pomp, Alfons L.; Dakin, Gregory F.; Spector, Jason A.; Plastic & Reconstructive Surgery. 128():12-13, October 2011; doi: 10.1097/01.prs.0000406221.46933.5a

Make Sure Your Surgeon is Trained for Your Procedure

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

Don’t simply look for a surgeon who is board certified.  Make sure they are trained to do the procedure you are having.  Yes, board certification is important, but the training is more so (in my humble opinion).

If you are having a breast augmentation, you don’t want a board certified maxillofacial surgeon or Ob-Gyn or neurosurgeon.  You want someone trained in plastic surgery.  It is a bonus if they are board certified.  By the same token, if you need brain surgery you don’t want a board certified plastic surgeon you want someone trained in neurosurgery. 

This rant was prompted by the USA Today article written by Jayne O’Donnell:  Lack of training can be deadly in cosmetic surgery

……….Sant Antonio is one of a soaring number of doctors who trained in other medical specialties, such as vision or obstetrics, but have branched into the more lucrative field of cosmetic surgery. Because state laws governing office-based surgeries often are lax, levels of training vary so widely that some doctors are performing cosmetic procedures after only a weekend observing other doctors. Sant Antonio himself has offered three-day liposuction training at his office for the last few years, according to interviews with doctors who have trained under him.

Some dentists trained in oral surgery now do breast implants; OB/GYNs perform tummy tucks, and radiologists are doing liposuction. The results can be disastrous, according to interviews with scores of victims, plaintiffs' lawyers and plastic surgeons, and a review of lawsuits. ………….

Bariatric Surgery Should Come Before Breast Reduction

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

Many women with large breast and weight issues seek breast reduction.  I was taught to encourage them to lose weight first.  Now there is a very small study that backs this up  (full reference below).

The American Society of Plastic Surgeons issued a press release entitled “Breast Reduction and Bariatric Surgery—Which Should Be Done First?” and provided the answer “ Final Results May Be Better When Weight Loss Comes First.”  I agree, but find it odd that such a small study was published.  There should have been more patients included.

Jeffrey A. Gusenoff, MD, and colleagues reviewed two groups of patients who sought consultation for body contouring surgery August of 2008 and February of 2010 after massive weight loss (defined as a weight loss of greater than 50 pounds).

Group I (n=15) included any patients who underwent reduction mammoplasty for symptomatic macromastia before massive weight loss.  Group II (the control group, n=14) included any patients who did not undergo breast surgery before massive weight loss.

The patients were given a prospective phone survey to assess self-ratings of breast appearance before and after breast reduction and after massive weight loss, ability to exercise, which would have preferred to have first—massive weight loss or breast reduction surgery—and what they would recommend to a friend.

Of the 15 patients (7.9%) in group I, 14 completed the survey (93%). 

For group I, all patients felt the appearance of their breasts improved after reduction (p < 0.001) but felt appearance worsened or stayed the same after weight loss (p = 0.003).

Seventy-one percent of patients were able to exercise more and 64 percent were able to lose weight on their own because of their reduction. ……..

Ten patients (71 percent) would recommend that a friend lose weight before breast reduction surgery. …

For group II, 79 percent of patients felt the appearance of their breasts worsened or stayed the same after massive weight loss (p = 0.03). ……

All 14 patients (100 percent) would recommend losing weight before undergoing breast surgery.

Even though I tend to agree that patients should loss weight prior to breast surgery.  It is much easier to achieve the cosmetic goals of the patient if she is at or near her goal weight.  Otherwise, the surgeon and patient are left to guess at how her skin will retract with weight loss and how much deflation or loss of volume will occur.

I wish the study had ask how many of the Group I patients desired an augmentation as part of their revision. 

Eleven patients (79 percent) felt a secondary lift following massive weight loss should be covered by insurance, and seven patients (50 percent) plan on having revision breast surgery.

They noted it with Group II patients

Eleven patients (79 percent) wished their breasts currently appeared different, with eight (57 percent) desiring lifted breasts, seven (50 percent) desiring general reshaping, two (14 percent) desiring reduced breasts, and two (14 percent) desiring larger breasts.

I have augmented four patients over my 21 years of practice who had previous breast reductions prior to losing weight (one was mine).  This should be included in the discussion as well as the high probability that a revision to reshape or re-lift the breasts will be needed if the reduction is done prior to the (massive) weight loss.

Related posts:
Reduction Mammoplasty (December 19, 2007)
Breast Reduction: Safe in the Morbidly Obese?—Article Review  (August 25, 2008)
Tennis Star Brings Breast Reduction Surgery into Press (June 4, 2009)
Impact of Obesity on Breast Surgery Complications – article review  (June 16, 2011)


REFERENCE

Reduction Mammaplasty, Obesity, and Massive Weight Loss: Temporal Relationships of Satisfaction with Breast Contour; Coriddi, Michelle; Koltz, Peter F.; Gusenoff, Jeffrey A.; Plastic & Reconstructive Surgery. 128(3):643-650, September 2011; doi: 10.1097/PRS.0b013e318221da6b

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.

…………………….

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)

Role Playing to Learn Communication

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

I was alerted to this Archives of Surgery article (full reference below) by MedPage Today:  Role Playing Boosts Surgical Residents' Bedside Manner.

I find it intriguing.  Role playing gives you a chance for a “do-over” when you make a social or communication faux pas. 

So much of medicine is communication.  Those of us who have been at it for years, deliver bad news differently (learned the hard way) now than we did previously.  You choose your words more carefully (though I still occasionally screw up).  Some words are more emotionally charged than others.  Some patients want more information than others. 

The University of Connecticut Health Center conducted a prospective study  of a pilot projected designed to  teach surgical residents patient-centered communication skills.

The study offered 44 general surgery residents the opportunity to participate in the three-part patient communication curriculum: A pre-test, training, and a post-test.  Only 30 completed all three parts.

The pre-test assessed general communication skills awareness of the resident while he/she delivered a new diagnosis of either breast or rectal cancer to a patient. The evaluation was done by a standardized patient instructor.

The training portion required residents to attend a 90-minute workshop that involved a lecture from a professor of surgery and formal instruction from the director of the center's clinical skills program, followed by a 30-minute role-playing session.

The post-test assessment re-evaluated the residents by the standardized patient in a crossover fashion (those who previously participated in a breast cancer diagnosis now participated in a rectal cancer diagnosis and vice versa).

The study authors concluded:

Residents' assessment of their patient communication skills indicates that there is an immediate need for a formal educational curriculum. Our results show that case-specific improvements seem more amenable to measurable improvement than general communications skills, at least with the limited short-term training that we used. Such skills can be assessed over a longer period, perhaps by incorporating this model and assessments from year to year.

Surgical and nonsurgical residency programs will benefit by helping residents incorporate patient needs and opinions into the care team's decision-making process. Principles such as emotional support, transition and continuity of care, provision of information and education, involvement of family and friends, and respect for patient values and preferences will form the basis of our educational series.

REFERENCE

Pretraining and Posttraining Assessment of Residents' Performance in the Fourth Accreditation Council for Graduate Medical Education Competency: Patient Communication Skills; Rajiv Y. Chandawarkar; Kimberly A. Ruscher; Aleksandra Krajewski; Manish Garg; Carol Pfeiffer; Rekha Singh; Walter E. Longo; Robert A. Kozol; Beth Lesnikoski; Prakash Nadkarni; Arch Surg. 2011;146(8):916-921.

Management of Latex Allergic Surgical Patient

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

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

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

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

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

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

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

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

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

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

Here’s my check list:

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

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

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

……

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

Their conclusions (bold emphasis is mine):

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

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

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

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

 

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

Is Prophylactic Mastectomy Worth It?

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

There is a recent article which asks this question (full reference below).  I think it is a question which must be answered on an individual basis.  

For someone like me, the answer would be no.  I have no family history or personal history of breast cancer.  I have small, more dense than fatty breast, but have always had normal mammograms.  I have never had any lesions which needed biopsy.

For an individual woman with a strong family history of breast cancer (especially genetically proven, BRCA1 and BRCA2) and a person history of breast cancer (ie right mastectomy for lobular carcinoma), then it is easy to say “Yes, a prophylactic left mastectomy would be worth it for you.”

In between these two examples is the gray area, and this article doesn’t necessarily make the gray area any clearer.

There is plenty of evidence that prophylactic mastectomy lowers the risk of breast cancer in the high–risk population in at least 95%.

The authors of the June 2011 Aesthetic Plastic Surgery Journal article performed a retrospective study by reviewing the records of all their patients (n=52) who underwent prophylactic mastectomy within a 25-year period to look at the aesthetic and long-term oncologic outcomes, complications, and patient satisfaction.

Of the 52 patients, 40 had the surgery on one side only (contralateral prophylactic mastectomy) and 12 had bilateral (bilateral prophylactic mastectomy), giving a total of 64 prophylactic mastectomies.

Of the 52 patients/ 64 mastectomies, there was 1 (1.56%) case of unexpected breast cancer in the mastectomy specimens.

Two thirds (42/64) were subcutaneous prophylactic mastectomies and the other third (22/64) were simple total prophylactic mastectomies.

Most of their patients chose to have reconstruction with implants (58/64 = 90.62%) while the other 6 (9.37)  chose to use autologous tissue --  5 (7.81%) received latissimus dorsi flaps with implants and 1 (1.56%) had a TRAM flap.

The complications included 4 (6.25%) breasts that developed capsular contracture, 2 (3.12%) cases of hematoma, and 1 (1.56%) infection.

More than 90% of the patients reported being either highly (39/52) or partially satisfied  (10/52).  Only 3/52 reported being unsatisfied. The authors report an overall aesthetic index of 8.8.

There were no deaths among their patients, nor any new development of breast cancer during the time period.

Related posts
Women Don’t Regret Prophylactic Mastectomy (May 5, 2011)

Prophylactic Mastectomy (January 28, 2009)

Advances in Nipple-Sparing Mastectomy – an article review (April 27, 2011)

Are Patients Making Good Decisions About Breast Reconstruction? (February 28, 2011)

REFERENCE

Prophylactic Mastectomy: Is It Worth It?; Jose Abel de la Peña-Salcedo, Miguel Angel Soto-Miranda, Jose Fernando Lopez-Salguero; Aesthetic Plastic Surgery, Volume 35 (3), June 2011;  DOI: 10.1007/s00266-011-9769-x

American Cancer Society:  What are the risk factors for breast cancer?

Should Langer’s Lines be Used for Incisions?

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

An old PRS journal article came to my attention recently thanks to a tweet by @prsjournal: “Most Emailed Article Langer's Lines: To Use or Not to Use: Thirty-six differently named guidelines have develope... http://bit.ly/mPR6v1”
[I’m not sure the time frame involved in the “most emailed.” Not sure if it’s for the day, the week, etc.] –
The tweeted article (first full reference below) is a short one and I would recommend it to young plastic surgeons and students.

A state of tension exists naturally in skin. For instance, wounded skin will gape, becoming elliptical instead of round. The first to notice this skin property was Dupuytren. In 1834, he encountered a corpse of a man who had stabbed himself with a round-tipped awl. Dupuytren noticed these stab wounds were elliptical instead of round. Then in 1838, Malgaigne wrote about the direction of these ellipses being different in different areas of the body. These two men did not drive home their point; Karl Langer, however, exhaustively studied the direction of these ellipses by stabbing a round-tipped awl into hundreds of cadavers. …….. but he is best remembered for his lines. ……….

In 1897, Kocher recognized the surgical importance of Langer's tension lines. He advised that surgical incisions follow these lines. However, Langer, an anatomy professor, did not intend for his lines to be used as guides for incisions. Later, Borges pointed out that Langer's lines represent lines of cleavage in cadavers and not lines of relaxed tension……….

Langer's lines are quite different from the relaxed skin tension lines of the face. These lines were described by Borges in 1962,and they are probably the most-accepted guide for incisions of the face………..

Langer's lines are almost perpendicular to Borges's relaxed skin tension lines in the areas of the scalp, forehead, glabella, midcheek, and lateral eye…………….

Cornelius Kraissl maintained that scars were least conspicuous when placed in wrinkle lines. … Kraissl recognized that wrinkles occurred perpendicular to muscle action. From this, he developed a scheme for elective incisions. However, these incisions might not be inconspicuous in patients without wrinkles or with ill-defined wrinkles. Also, wrinkle lines do not always coincide with Borges's relaxed skin tension lines. Hence, Borges's lines are the best guide for elective incisions of the face. …………….

Developed from cadavers with extremities in extension, Langer's lines are longitudinal over joints. Blocker and Hendrix recognized that Langer's longitudinal lines predisposed patients to contractures when they were used over joints. Oriented perpendicular to muscle action, Kraissl's lines have a more transverse orientation than Langer's. Accordingly, Kraissl's transverse lines of the upper extremity do not predispose patients to contracture formation. ……….

Many other factors contribute to the camouflaging of scars, including wrinkle and contour lines. Learn how to assess the direction of least tension on the wound and orient the closure accordingly.

Borges's and Kraissl's lines are better guides for elective incisions in the face and body, respectively, than Langer’s lines. Remember, they are only guidelines. (photo scanned in from 2nd reference article)

REFERENCE

1. Langer's Lines: To Use or Not to Use; Wilhelmi, Bradon J.; Blackwell, Steven J.; Phillips, Linda G.; Plastic & Reconstructive Surgery. 104(1):208-214, July 1999

2. The Selection of Appropriate Lines for Elective Surgical Incisions; Kraissl, Cornelius J; Plastic & Reconstructive Surgery. 8(1):1-28, July 1951.

3. Relaxed Skin Tension Lines (RSTL) versus Other Skin Lines; Borges, Albert F.; Plastic & Reconstructive Surgery. 73(1):144-150, January 1984.

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

Women Don’t Regret Prophylactic Mastectomy

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

I was alerted to the presentation at the American Society of Breast Surgeons meeting (first reference below) by Judy Boughey, MD by @MedicalNews’ tweet:

ASBS: Prophylactic Mastectomy Good Even Years Later (CME/CE) http://bit.ly/kMCsdr

Boughey and colleagues note that previous researchers using cross-sectional surveys have found that the majority of women are satisfied with their decision to have contralateral prophylactic mastectomy (CPM) one to several years after the procedure.

Their study chose to look at the consistency of satisfaction and changes in adverse effects in the same women with longer term follow-up.

To do this, they surveyed a previously established cohort of women with unilateral breast cancer who had contralateral prophylactic mastectomy at the Mayo Clinic between 1960 to 1993. All of the women had a positive family history.  All were surveyed at two time points and the results compared.

The initial survey was done at a mean of 10.3 years after prophylactic mastectomy (second and third references below).  This survey involved 583 women.

Of the 583 women who responded to the initial survey, 523 were alive and resurveyed 10 years later. Data from both surveys are available for analysis on 269 women.

The researchers found the majority of women continued to be satisfied with their decision to have contralateral prophylactic mastectomy (86% initial survey; 90% follow-up survey, p=0.06).

Similar numbers to that of the initial survey reported neutral feelings or dissatisfaction with their CPM decision on follow-up survey (8% and 6%, respectively, initial survey; 4% and 6% follow-up survey).

There was no significant change in the proportion indicating they would choose CPM again, but as with satisfaction, the proportion was slightly higher on the follow-up survey (95% initial survey; 97% follow-up survey, p=0.27).

The most frequently cited adverse effects were similar at both time points and included body appearance (29% vs 31%, initial vs follow-up survey, p=0.61), sense of femininity (21% vs 24%, p=0.25) and sexual relationships (24% vs 23%, p=0.68).

From the MedPage News article:  "This information is useful in the education of patients and physicians," said Boughey. "Patients should consider their choice carefully and be made aware of adverse events. However, those that decide for contralateral prophylactic mastectomy are likely to remain satisfied with the decision in the long term."

A related post of interest is one from Dr. Dialogue:  Is Watchful Waiting too Difficult? (originally posted there on March  13, 2010 and on Better Health on May 1st, 2011:  Why Double Mastectomies Are Popular: Watchful Waiting Is Too Difficult?)

REFERENCE

1.  Contralateral prophylactic mastectomy: Consistency of satisfaction and psychosocial consequences over time;  Boughey JC, et al; ASBS 2011; Abstract 1693 (pdf file)

2.  Satisfaction After Contralateral Prophylactic Mastectomy: The Significance of Mastectomy Type, Reconstructive Complications, and Body Appearance; Frost MH, Slezak JM, Tran NV, Williams CI, Johnson JL, Woods JE, Petty PM, Donohue JH, Grant CS, Sloan JA, Sellers TA, Hartmann LC;  JCO Nov 1, 2005:7849-7856; DOI 10.1200/JCO.2005.09.233.

3.  Contralateral Prophylactic Mastectomy: Efficacy, Satisfaction, and Regret (Editorial); Marc D. Schwartz; J Clin Oncol 2005, 23: 7777-7779; DOI: 10.1200/JCO.2005.08.903

Advances in Nipple-Sparing Mastectomy – an article review

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

There is a very nice review article of the advances in nipple-sparing mastectomy surgery in the March 2011 issue of the Aesthetic Surgery Journal (full reference below).

Dr. Patrick Maxwell and colleagues includes some history of nipple-sparing mastectomy (NSM):

NSM was attempted in the 1980s but never gained popularity owing to the controversies surrounding oncological safety. Now, better technologies for preoperative staging and assessment of lesion distance from the NAC, along with an increased understanding of the anatomy of the breast ducts with relation to the nipple, are encouraging a return to the concept. One of the key publications that renewed and increased enthusiasm for this technique was the multicenter publication of 192 patients undergoing NSM with only four recurrences, all of which occurred distant from the NAC. Recurrences were seen in the upper outer quadrant, where nearly all recurrences are found with simple mastectomies, at the junction of the tail of the breast and axillary tissue.

In recent years, there has been a sudden increase in reports of NSM for prophylaxis and cancer treatment. Of the approximately 1868 NSM procedures performed for breast cancer treatment and published in recent literature, only three local recurrences within the NAC have been reported, representing 0.16% of local events attributed to patients with NAC preservation. Note, however, that most of these studies have short follow-up periods, thus rendering definitive conclusions premature.

While NSM is not an option in all cases, it is an option that when available is worth using.  No surgeon can create a nipple as lovely as the one that would be removed by the mastectomy, so if it can be used it greatly adds to the finished results.

Exclusion criteria included tumors larger than 3 cm, clinical invasion of the NAC, tumors within 2 cm from the nipple, evidence of multicentric disease, a positive intraoperative retroareolar frozen section, and nodal disease, excluding isolated immunohistochemistry positivity.

The article does a quick review of some of the techniques for NSM (photo credit, 1st reference article):


The article is worth your time to read.



REFERENCES

1.  Advances in Nipple-Sparing Mastectomy: Oncological Safety and Incision Selection;  Maxwell G.P., Storm-Dickerson T, P Whitworth P, Rubano C, and Gabriel A; Aesthetic Surgery Journal March 2011 31: 310-319, doi:10.1177/1090820X11398111

2.  Nipple-Sparing Mastectomy for Breast Cancer and Risk Reduction:  Oncologic or Technical Problem?; Sacchini V, Pinotti JA, Barros AC, et al; J Am Coll Surg 2006;203:704-714

The Angry Face Syndrome

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

I must say when I first read the title of this article (full reference below) I thought it was a joke. Apparently, I was just unaware this syndrome exist.

The authors state, “The finding of frontal bossing, deep radix, straight nasal dorsum, and an over projection of the nasal tip constitutes the angry face syndrome.” (photo credit, from article)

The authors note, “When the syndrome components of frontal bossing, a deep radix, and nasal tip projection are present but include a significant nasal dorsal hump (instead of a straight dorsum), the angry face syndrome does not apply. Somehow the dorsal hump negates the message of anger to the observer.”

Their solution is a rhinoplasty

with attention to a major radix augmentation graft and substantial reduction of the nasal tip projection. In addition, as with the illustrative cases described herein (Figures 1, 2, and 3), we also correct other offending features at the same time (eg, dependent nasal tip, boxy tip, poor alar support, alar base width, wide nasal bones).

Their conclusion:

In all of our years of teaching rhinoplasty, we have always maintained that in considering surgery, the patient must understand that nothing in the external world will change because the of the patient's rhinoplasty. The only thing that will change is the way the patient feels about himself or herself, ie, their self-esteem.

Rhinoplasty for the angry face syndrome, however, may be the exception to the rule.

REFERENCE
The Angry Face Syndrome; Pastorek NJ, White WM; Arch Facial Plast Surg 2011;13(2):131-133; doi:10.1001/archfacial.2011.14

Florida Student Gets Hand Transplant

 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.

This is a difficult post for me to write.  As much as I admire the surgeons who are pushing this new advance I found myself bothered by this one.  Why?     That’s what I have been asking myself.  After all, Linda Lu, 21 year old, is a college student from Orlando, Florida is ecstatic about the new hand.

"I've already accepted it as my hand since the day I woke up," Linda Lu said during a Monday press conference at Emory University Hospital in Atlanta, where the surgery took place. "But just looking at it, sometimes I still can't believe that it's there... It kind of feels like magic."

"I'm in information technology," Lu said. "So, my primary goal is to be able to type."

Simple enough goal, isn’t it?   When playing the “what would I give up game” my hands are never given up easily.  I could probably learn to sew with only one hand, but it would be difficult and it would become mostly machine sewing.  I could still blog as I could type with one hand – not as fast, but it would get done. 

I would not be able to do surgery with one hand, but a hand transplant would not give that back to me anyway.  The dexterity would never be good enough.

Linda is reported to have lost her left hand when she was 1 year old.  The amputation was done due to complications from Kawasaki disease.

Still I’m left with this uneasy feeling.  Most people born with only one hand/arm adjust well.  For example, look at the baseball pitcher Jim Abbott. 

This healthy young woman will now be placed on anti-rejection medications for life.  It will make any pregnancies she has high-risk ones.  She will be more susceptible to infections.  Some anti-rejection medications increase the risk of cancers.

Just because we can do a procedure doesn’t mean we always should.  I hope my uneasiness regarding this one is misplaced.  After all, I am getting my information from news articles and not from a discussion with the patient.

Newsprint articles

Florida Student Receives Rare Hand Transplant Surgery, FoxNews.com, March 28, 2011

Valencia student has rare hand transplant at Emory University, LA Times, March 28, 2011 (video as well as print)

Related posts:
Double Hand Transplant on Twitter  (August 26, 2010)
Cost of Hand Transplantation?  (September 22, 2010)
Rejection  (December 1, 2010)
New Technology May Help Prevent Rejection in Hand Transplant Patients (December 13, 2010)

Following Instructions

“Take one to two pain pills by mouth every 4 to six hours”

To me that is clear.  I was reminded recently that it isn’t to all patients. 

A patient complained of lack of relief from her pain medicines after surgery.  Her description of the pain didn’t suggest any complications so I ask how she was taking them.  I was looking for a way to safely use NSAIDS or tylenol as a boost rather than giving her something stronger.

“I take one pain pill and then wait an hour to take another one.”
I prompted her to tell me when she took the next dose.
“I wait four hours and then take one pain pill, but I wait for six hours to take the next one.”

Ah!

I had mentioned to her and her caregiver that due to her small size she should begin with just one, then wait for 30 minutes to an hour to see if she needed the second one.  They were doing that, but the other part wasn’t clear.

“Take one to two pain pills by mouth every 4 to six hours”

1.  Take one pain pill every 4 hours.

2.  Take two pain pills every 4 hours.

3.  Take one pain pill every 6 hours.

4.  Take two pain pills every 6 hours.

….

Oh, but there are really more options aren’t there:

1.  Take one and half pain pill every 4 hours.

2.  Take one pain pill every 5 hours.

….

So she was taking the medicine in a correct way, but it wasn’t the optimal one for her.  We had a short discussion which seemed to help.

……………………..

There is much discussion about patients and compliance in taking medicine.  It starts with the physicians, nurse, and pharmacists.  I have to write good instructions.  Sometimes this is difficult to do and keep them short enough to go on the label.

With pain medicines it is nice for patients to know there is a range of effective, safe dosages. 

U.S. Pharmacopeia has proposed labeling standards which can be viewed here. Comments on the proposed standards may be submitted to 17PrescriptionContainerLabeling@usp.org through March 31, 2011.  One of the changes is:

Give explicit instructions—Instructions should clearly separate the dose itself from the timing of each dose and use numeric characters (e.g., “Take 2 tablets in the morning and 2 tablets in the evening” rather than “Take two tablets twice daily”). …

Ambiguous directions such as ‘‘take as directed’’ should be avoided unless clear and unambiguous supplemental instructions and counseling are provided (e.g., directions for use that will not fit on the prescription container label)

First Full Face Transplant in US

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

It continues to amaze me that colleagues are able to do such marvelous work to improve the lives of some.  For Dallas Wiens, 25, the benefits and hope of an improved life outweigh the risks of surgery and rejection (transplant).

He is a construction worker from Ft. Worth, TX who suffered severe burns to his head two and a half years ago when the boom lift he was operating drifted into a nearby power line. The nearly fatal accident left him in a coma for three months.

Related posts
Face Transplantation – First in the US Done (December 18, 2008)
Appearance Is A Function of the Face (December 30, 2009)
More on Facial Transplantation (March 1, 2010)
First Full Face Transplant Done!  (July 12, 2010)
Facial Prosthetics Restores Face (August 5, 2010)
First Full Face Transplant Done! (July 12, 2010)
Facing Monday  (January 24, 2011)

Stopping Smoking Before Surgery

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

Physicians and surgeons all agree on the link between smoking and postoperative complications.  We don’t agree (or know) how much time is required between cessation of smoking and surgery for optimal risk reduction.

Dr.Thomas Fiala wrote a nice blog post, Smoking Cessation and surgical complications, recently  discussing the 3rd reference article below.

Smokers that quit smoking before surgery had 41% fewer complications. The researchers found that each week of cessation increases the effect by 19%.

Trials of at least 4 weeks' smoking cessation had a significantly larger treatment effect than shorter trials (P = .04).

Smokers that quit had lower rates of total complications, fewer wound healing complications, and fewer pulmonary complications.

The first two articles referenced below were evaluated in an article written by Michael Smith for MedPage Today:  Smokers Who Quit Preop Seem to Do Okay Postop.  Those two articles looked at pulmonary complications not wound healing complications.

There was also no significant benefit or harm when the analysis was restricted to the three studies with biochemical validation of quitting, the researchers reported. The relative risk was 0.57, with a 95% confidence interval from 0.16 to 2.01.

As noted by Clara and Chow (2nd reference, review of 1st reference article) (bold emphasis is mine):

While the review performed by Myers et al provides valuable information, it does not definitively answer the question raise……

Physicians should ideally try to get their patients to stop smoking several months prior to their surgery. The appropriate advice regarding the optimal timing of smoking cessation for patients seen close to their scheduled surgery awaits further research.

I tend to agree with Dr. Fiala who writes, “There is no safe minimum number of cigarettes that you can sneak before surgery. Even a couple can do you in.”

Related posts
Smoking in Facial Aesthetic Surgery Patients (December 28, 2009)


REFERENCES

1.  Stopping smoking shortly before surgery and postoperative complications: A systematic review and meta-analysis; Katie Myers; Peter Hajek; Charles Hinds; Hayden McRobbie; Arch Intern Med. 2011;0(2011):archinternmed.2011.97.

2.  The optimal timing of smoking cessation before surgery; Clara K. Chow; P. J. Devereaux; Arch Intern Med. 2011;0(2011):archinternmed.2011.88.

3.  Smoking Cessation Reduces Postoperative Complications: A Systematic Review and Meta-analysis; Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO; The American Journal of Medicine - February 2011 (Vol. 124, Issue 2, Pages 144-154.e8, DOI: 10.1016/j.amjmed.2010.09.013)

Shout Outs

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

Amy, Diabetes Mine, is the host for this week’s Grand Rounds! You can read this week’s edition here.

The Ides of March is the first day of the Roman New Year. It also marks the first day of spring in the Roman calendar.

On this day in history, Julius Caesar was warned by soothsayers to “beware of the Ides of March”. Apparently, he did not heed the warning strongly enough as he was stabbed by Marcus Brutus on the Ides of March in 44 BC.

We must begin with last week’s betrayal by the forces of nature, as Dr. Paul Auerbach, of Stanford Emergency Medicine, voices our feelings at Heathline:

“Our thoughts and prayers go out to everyone in harm’s way related to the earthquake and tsunami that just struck Japan, as they did for persons in New Zealand, Haiti, and every other country recently affected by a natural disaster.”  ……

……………………………

A wonderful post by Michelle Au, the underwear drawer :  it gets better

The lowest point in my residency was in January of my intern year.  I was a Pediatrics resident back then, doing a month-long rotation on "Team 2," which is what we called the general inpatient pediatric team, with a focus on the patients on our liver transplant service.
It was a very long month.…………..

……………….………….

Via both @movinmeat and @inwhiteink:  Satellite Photos - Japan Before and After Tsunami - Interactive Feature - NYTimes.com

and to @movinmeat:  @arclight this is an excellent, if long/wonky explanation of what happened at Fukushima Daichi nuclear plant Why I am not worried about Japan’s nuclear reactors

New York Times:  100 Photos of Japan Aftermath

…..
If you are looking for ways to help Japan, consider donating to the Red Cross:  Japan Earthquake and Pacific Tsunami Relief
or if you’d rather do so by texting:  Donate to @SalvationArmyUS by texting "JAPAN" to "80888" or text "REDCROSS" to "90999"
Other good sources for information can be found in Thomas Fiala, MD’s post:  OT:  Information on Japanese earthquake & tsunami relief efforts

…………………………………………

Two stories from NPR:

Radiation Fears Rise At Japanese Plant by NPR Staff and Wires

Dangerous levels of radiation are leaking from the earthquake-crippled Fukushima Daiichi nuclear power plant north of Tokyo and levels are rising, Japanese Chief Cabinet Secretary Yukio Edano said Tuesday.

Japanese Prime Minister Naoto Kan ordered everyone within 20 kilometers (about 12 miles) to evacuate. He told everyone within 30 kilometers (about 19 miles) to go inside. Japan's NHK television said most residents inside the 20-kilometer radius have already evacuated.  ………….

Why Iodine Tablets Come Out When Radiation Threatens by Scott Hensley

Just in case, Japan has distributed a whole bunch of potassium iodide to evacuation centers near the troubled Fukushima Daiichi and Fukushima Daini nuclear power plants.

The International Atomic Energy Agency said in a statement that 230,000 units (the stuff comes in tablets and as a liquid) are at the ready.

Why is that important? Well, one of the substances that can be released in a nuclear accident is radioactive iodine (I-131, if you're interested in the details). And some radioactive iodine has already been detected by Japanese authorities.  ……….

……………………………..

H/T to @globalsurgeon: An interview in IPS News of @ReinouGroen from @SurgeonsSOS on #globalsurgery : Needing Surgery Shouldn't Be a Death Sentence 

Surgery saves the lives of millions of people around the world, but only a tiny percentage of them live in low- and middle-income countries (LMICs), where a shortage of skills, supplies and infrastructure can turn easily treatable accidents and illnesses into lifelong disabilities and even death.

The world's poorest receive only four percent of all major surgical operations worldwide, while 75 percent of surgeries benefit the richest third of the world, according to a 2010 Harvard University School of Public Health study.  …….

………………………………

Our medical blog friend, Dr Anonymous, has officially ended his old blog:  Goodbye @doctoranonymous.   He changed his twitter name last week: @drmikesevilla and has revealed his new website/blog:  Family Medicine Rocks. 

Best wishes to you, Dr. Sevilla!

……………………….

On a lighter note, this story comes from @KnittingNephron  ---Knitted breasts created by 91-year-old pensioner

You might expect your granny to knit you a woolly jumper, but one pensioner has been defying expectations by using her needles to craft amazing knitted BREASTS.

Coral Charles-Dunne, 91, from Birmingham, has knitted dozens of the unusual educational tools as part of a project to inform expectant and new mums about breastfeeding.

She says spends about two hours creating each of the woolly boobs and makes them in a range of sizes, knitting for up to six hours per day. …………