Thursday, July 31, 2008

Gynecomastia -- a repost

 Updated 3/2017-- photos and all links (except those to my own posts) removed as many are no longer active and it was easier than checking each one.

This is a repost from last August with a few additions.
Gynecomastia is defined as benign, excess breast tissue development in male individuals. Recent studies have reported an overall incidence of 32 - 36 %, and up to 64.6 % in adolescent boys. The incidence of bilateral involvement also varies in the literature from 25 -75 percent of patients. The underlying cause seems to be an increase in the ratio of estrogen to androgen activity. 
In general physiologic gynecomastia can be observed in three peaks during life.
  1. The neonatal period: 60-90% of infants have transient gynecomastia due to transplacental transfer of maternal estrogens.
  2. Puberty: 48-64% of boys at puberty have gynecomastia. Usually peak age of onset is between 13 and 14 years, followed by a decline in late teenage years.
  3. Late in life: The highest prevalence of gynecomastia is seen among men aged 50-80 years.
Pathologic gynecomastia occurs as a result of various metabolic disorders (alcoholic cirrhosis), endocrine disorders (hyperthyroidism, adrenal cortical hyperplasia), acquired hypogonadal states (orchitis, testicular trauma), congenital hypogonadal states (Klinefelter syndrome, congenital anorchia), and increased estrogen states (bronchogenic carcinoma, testicular tumors). (Table 1--MedScape article)
Pharmacologic gynecomastia occurs by several mechanisms, including increased direct estrogenic activity, increased secretion of estrogen, decreased testosterone synthesis, and decreased androgen sensitivity. There are also many drugs with poorly understood mechanisms that are associated with gynecomastia. (Table 2--MedScape article)
Clinical evaluation of patients with gynecomastia is very important. However, further work-up is rarely indicated.
History should include age, duration and onset of breast enlargement, symptoms of pain or tenderness, medications and recreational drug use, and psychological and social effects. A review of systems that covers all the above mentioned causes should be obtained.
Physical examination of the breasts should involve assessment for glandular or fat predominance (by the pinch test), degree of glandular ptosis, skin excess, nodules/masses, and nipple abnormalities or discharge. Glandular or parenchymal tissue is characterized by rubbery breast tissue that is mobile and extends from a subareolar, centric position. Breast cancer accounts for 0.2% of all malignancies in men and generally presents as a unilateral firm mass, often eccentric in location rather than centered beneath the areola. This should be remembered if any suspicious nodules or masses are found. These may have abnormal firmness, overlying skin ulceration, eccentric location, or abnormal nipple discharge.
The normal male breast is typically flat with some fullness around the nipple-areola complex. The nipple-areola complex is normally 2 - 4 cm in diameter (average, 2.8 cm) and located over the fourth intercostal space. Nipple to sternal notch distance is, on average, 20 cm. A muscular male chest may exhibit superior fullness with a transition to a flat inferior chest near the inframammary fold. Completion of the physical examination should in particular assess for testicular enlargement/atrophy and asymmetry, thyromegaly, hepatomegaly, pulmonary abnormalities, and abdominal masses. Additional diagnostic testing should be individualized to address abnormalities identified in the history or physical examination.
The majority of patients with gynecomastia require no treatment other than removal of the precipitating cause. If it is drug-induced, it may regress if the offending medication is stopped. Treatment of hyperthyroidism, correction of hypogonadism and surgical removal of testicular, adrenal or other causative tumors can also lead to regression.
Treatment for gynecomastia is indicated in cases where it produces significant pain, embarrassment or emotional discomfort and therefore interfering with the patient's life. A patient should consider proceeding with surgical management once diagnosis of gynecomastia is established of nonphysiologic causes or of duration greater than approximately 12 months, because hypertrophic breast tissue beyond this stage usually becomes irreversibly fibrotic.
Classification of gynecomastia as defined by Rod Rohrich, MD & others is based on the amount and character of breast hypertrophy and the degree of ptosis.
Grade I patients --minimal hypertrophy (less than 250 gm of breast tissue).
  • Grade IA--primarily fatty breast tissue. Suction-assisted lipectomy can be used with great success.
  • Grade IB--primarily fibrous breast tissue
Grade II patients -- moderate hypertrophy (between 250 and 500 gm of breast tissue).
  • Grade IIA--primarily fatty breast tissue. Suction-assisted lipectomy can be used with great success.
  • Grade IIB--primarily fibrous breast tissue
Grade III --severe hypertrophy (more than 500 gm of breast tissue), grade 1 ptosis
Grade IV --severe hypertrophy (more than 500 gm of breast
tissue), grade 2 or 3 ptosis
Ultrasound-assisted liposuction is effective in all grades of gynecomastia. Usually, no further treatment is needed in grade I or II gynecomastia. Often, single ultrasound-assisted liposuction treatment is all that is necessary for grades III and IV, especially in those with mild ptosis and good skin quality. Often the glandular tissue will need direct excision which can be done through a small peri-areolar incision. If removal of redundant skin and/or resistant lipodystrophy is still required after ultrasound-assisted liposuction, a staged excision is delayed for 6 to 9 months to allow for maximal skin retraction and healing, thus potentially allowing down staging of the magnitude of the excisional technique (and therefore minimizing scarring)

Classification and Management of Gynecomastia: Defining the Role of Ultrasound-Assisted Liposuction.; Plastic & Reconstructive Surgery. 111(2):909-923, February 2003; Rohrich, Rod J. M.D.; Ha, Richard Y. M.D.; Kenkel, Jeffrey M. M.D.; Adams, William P. Jr., M.D.
Breast Cancer in a Patient with Gynecomastia; Plastic & Reconstructive Surgery. 84(6):976-979, December 1989; Fodor, Peter Bela M.D.
Management of Gynaecomastia: An Update ; Int J Clin Pract. 2007; 61(7):1209-1215.; P. Gikas, MD; Kefah Mokbel, MS, FRCS (also a MedScape article)
Gynecomastia--eMedicine article, June 9, 2006; Ali Fawzi, MD
Additional References & Info
Gynecomastia, eMedicine Article, Nov 15, 2006; Mark R Allee MD and Mary Zoe Baker MD
This is a very nice youtube video (some of it is graphic)

Wednesday, July 30, 2008


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

I learned a new word recently.
adjective: Having well-shaped buttocks.
From Greek calli- (beautiful) + pyge (buttocks). Two related words are dasypygal and steatopygia.
"And it hasn't been lost on modern film directors that a nice set of tights can showcase the callipygian assets of a well-formed leading man."
Heroes in Hosiery; South China Morning Post (Hong Kong); Jul 20, 2006
I am being asked by more and more patients about buttock shaping, lifting, and even implants. The entire idea of defining a nice buttock is interesting to me. Difficult to put into words, but something "you know when you see" one. And yes, I do check out men's butts. The girls in the OR and I have been know to whisper about how nice Dr ___'s butt looks in his scrubs.
Okay, back to the topic. What defines a well-shaped buttock?
The features that are common to attractive youthful, female buttocks in all ethnic groups include:
  • A smooth inward sweep of the lumbosacral area and waist.
  • A very feminine cleavage as the buttocks separate superiorly and inferiorly.
  • Maximum prominence in the mid to upper buttocks.
  • There should be minimal infragluteal crease, with no droop above this line.
Sacral dimples or depressions may be present or absent in attractive youthful buttocks, but are not considered a determinant of their beauty.
Even with the difference in cultural ideas of the "ideal" buttock, the above features hold. Some ethnic differences include (some good photos can be found here):
Caucasian patients
  • will generally want buttocks that are full but not really large.
  • fullness of the lateral thigh is considered objectionable.
  • Some prefer a full rounded lateral buttocks.
  • Others prefer a flat or hollow lateral buttock (considered a more "trim" or athletic look).
Hispanic or of recent Hispanic descent
  • prefer buttocks that are very full.
  • lateral buttocks that are very full
  • a slight fullness in the lateral thigh.
Asian patients
  • prefer buttocks that are shapely but small to moderate in size
  • little or no fullness in the lateral buttocks or lateral thigh.
African-Americans and Caribbean's of African descent
  • have a strong and consistent cultural ideal of very large buttocks
  • often will request a "shelf" (extreme prominence of the upper buttocks)
  • prefer very full lateral buttocks
  • a very full, prominent trochanteric area of the lateral thighs is considered attractive by both men and women in this culture
There are multiple procedures that can be used to get to or closer to the "ideal" (must in keep in mind the patient's ideal) buttock. These include:
Micro-fat grafting
Buttock Reduction/Contouring
Gluteal Implants
Buttock Lifts
Combination of the Above
And don't forget these exercises that help tone and bulk up the glutes. You can find them here or a video here or this youtube video (the one below) or this one,

Dr Thomas L Roberts, III, MD, FACS Website: (nice photos and patient information)
Body Contouring, Buttocks Surgery; eMedicine Article, Dec 19, 2006; Robert F Centeno MD and Neal R Reisman MD, JD
Body Contouring, Flankoplasty, and Thigh Lift; eMedicine Article, Feb 25, 2008; Keith M Robertson MD and Bruce G Freeman MD
Beautiful Buttocks: Characteristics and Surgical Techniques. Clin Plast Surg, July 2006;33(3):321-32; Cuenca-Guerra R, Lugo-Beltran I (abstract available here)
Buttocks Lifting: How and When to Use Medial, Lateral, Lower, and Upper Lifting Techniques; Clin Plast Surg. July 2006;33(3):467-78; Gonzalez R. (abstract available here)
Gluteoplasty; Aesthetic Surgery Journal, Vol 23, No 6, pp 441-455; Constantio G Mendieta MD (abstract available here)
Gluteal Aesthetic Unit Classification: A tool to Improve Outcomes in Body Contouring; Aesthetic Surgery Journal, Vol 26, No 2, pp 200-208; Robert F. Centeno MD (abstract available here)
Gluteal Reshaping; Aesthetic Surgery Journal, Vol 27, No 6, pp 641-655; Constantino G Mendieta MD (abstract available here)

Tuesday, July 29, 2008

Shout Outs

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

Grand Rounds is up over at Dr Edwin Leap's place. His theme was "Why we do it". Nicely done and some very nice posts. Read this week's grand rounds here.
Welcome to Grand Rounds! This is my first time hosting, so thanks for your patience as I stumble through. And thanks to everyone who submitted! There are some extremely insightful folks out there, and I’m grateful to showcase their thoughts.

Change of Shift is up over at Emergiblog. This is the start of a new year (and with a new logo):
Welcome to Volume 3, Number 2 of Change of Shift!
New year, new logo!
I tried, I really tried, to make a logo that wasn’t blue but I just could not do it.
I just love blue on blogs!
Many thanks to all who have contributed this week, and to those who contributed but don’t realize it yet!

Dr Wes and Dr Rob are working together to help "pinch childhood brain cancer".
with Zippy, the lovable red lobster, to raise awareness and funds to support childhood brain cancer research over at He asked if we'd help support the effort and host the official "Fun With Zippy" t-shirt on our medical t-shirt site, for which we were only too happy to help out.
All proceeds from the sales of these shirts, button, aprons, mouse-pads, stickers and the like with Zippy's logo will support childhood brain cancer research.

Dr Anonymous' Blog Talk Radio show will be back on air this Thursday night! His guest this week will be Dr Theresa Chan whose blog is Rural Doctoring. It is a wonderful addition to the blogosphere. The show starts at 8 pm CST (or 1 am GMT). I hope you will join us.
Tips for first time Blog Talk Radio listeners (from Dr A):

A nice post by Dr Val yesterday (though aren't they all nice)
I attended a lecture entitled, "Limb Labs: Getting Amputee Soldiers Back to Work After World War I." The lecture was held at the National Museum of Health and Medicine on the Walter Reed campus in Washington, DC. Both lecturers (Beth Linker and Jeffrey Reznick) did a wonderful job of transporting the audience back in time, outlining the cultural beliefs and historical context of the day. This is what I gleaned from their lectures:
Dr Wes will be doing a live on-line chat for an hour on August 6th, 2008 at 7PM CST. He recently did an hour-long radio show on atrial fibrillation (afib) with his colleague Dr. Jose Nazari, MD. The podcast is now up and can be listened to or download it here.

Monday, July 28, 2008

Methylene Blue and Skin Necrosis -- Repost

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

I "conversed" with a young woman this weekend via e-mail who has this complication. So I thought I would repost my review of it from December 2, 2007.
Sentinel lymph node (SLN) dissection has increased in use for the management of high-risk melanoma and other cancers, such as breast cancer. The procedure identifies an SLN by intradermal or intraparenchymal injection of a blue dye (either isosulfan blue or methylene blue), a radiocolloid, or both around the primary malignancy.
When isosulfan blue is used there is a 2% incidence of allergic reactions. These include "blue hives" and anaphylaxis. Because of these reactions, the use of methylene blue is becoming more wide spread as no toxicity has been attributed to it.
The use of methylene blue requires an intraparenchymal injection of 5 mL of 1% methylene blue dye. While methylene blue has had no systemic toxicity attributed to it, it has been associated with a local inflammatory reaction which may lead to skin necrosis at the site of injection. Stradling et al. reported skin lesions in 5 of 24 patients who received intradermal injection of methylene blue dye for lymphatic mapping in breast cancer. The skin lesions included a variety of local inflammatory presentations, including erythematous macular lesions, superficial ulcers, necrotic ulcerations, and abscess formation. After injections were restricted to the deep parenchyma, no further skin lesions were noted. This local toxicity of methylene blue with superficial injection concerns surgeons who perform subareolar injection because of its potential effect on the nipple/areolar complex.

Methylene Blue should not be given by subcutaneous, so try to inject into the deep dermis or subcutaneous layer. This should help prevent the skin complications.
"Some individuals have found that dilution of methylene blue (2 mL of methylene blue and 3 mL of saline) allows successful mapping while avoiding this local toxicity (Pat Whitworth, MD, personal communication, May 2004" -- from second reference article.

Treatment consists of basic wound care.
1) Keep the wound clean.
2) Keep the wound moist.
3) Keep the wound well nourished, which implies reducing or eliminating edema and keeping pressure off the wound.
4) Debride only as necessary, be conservative.

Methylene Blue Solution for Injection Data Sheet--MedSafe
Is Blue Dye Indicated for Sentinel Lymph Node Biopsy in Breast Cancer Patients With a Positive Lymphoscintigram?; Amy C. Degnim, MD, Kevin Oh, MD, Vincent M. Cimmino, MD, Kathleen M. Diehl, MD, Alfred E. Chang, MD, Lisa A. Newman, MD, MPH and Michael S. Sabel, MD; Annals of Surgical Oncology 12:712-717 (2005)
Adverse skin lesions after methylene blue injections for sentinel lymph node localization; Stradling B, Aranha G, Gabram S; Am J Surg 2002;184:350–2.
Allergic reactions to isosulfan blue during sentinel node biopsy – a common event; Cimmino VM, Brown AC, Szocik JF, Pass HA; Surgery. 2001;130:439–42. doi:10.1067/msy.2001.116407.
Dye Rashes; Raimer SS, Quevedo EM, Johnston RV; Cutis. 1999;63:103–106
The Role of Subareolar Blue Dye in Identifying the Sentinel Node in Patients with Invasive Breast Cancer by K. Mokbel and A. Mostafa-- MedScape Article

Sunday, July 27, 2008

The Big Read

I saw this on Purplesque's blog (thanks Vijay for the introduction). It seems to be a meme going around the blogosphere rather than a list coming from the come from National Endowment for the Arts (NEA). The NEA does have a program called "The Big Read".
The Big Read is an initiative of the National Endowment for the Arts designed to restore reading to the center of American culture. The NEA presents The Big Read in partnership with the Institute of Museum and Library Services and in cooperation with Arts Midwest.
Still it is interesting to read the "meme list" and see which ones you have read. So here it is:
“The Big Read reckons that the average adult has only read 6 of the top 100 books they’ve printed.”
1) Bold: I have read.
2) Underline: Books I love.
3) Reprint this list in your own blog so we can try and track down these people who’ve read 6 and force books upon them ;-)
1. Pride and Prejudice - Jane Austen
2. The Lord of the Rings - JRR Tolkien
3. Jane Eyre - Charlotte Bronte
4. The Harry Potter Series - JK Rowling
5. To Kill a Mockingbird - Harper Lee
6. The Bible
7 . Wuthering Heights - Emily Bronte
8. Nineteen Eighty Four - George Orwell
9. His Dark Materials – Phillip Pullman
10. Great Expectations – Charles Dickens
11. Little Women - Louisa M Alcott
12. Tess of the D’Urbervilles - Thomas Hardy
13. Catch 22 - Joseph Heller
14 . The Complete works of Shakespeare (Like Purplesque I've tried, and failed. Have seen many of them performed.)
15. Rebecca - Daphne Du Maurier
16. The Hobbit --J.R.R. Tolkien
17. Birdsong – Sebastian Faulks
18. Catcher in the Rye - JD Salinger
19. The Time Traveler's Wife
20. Middlemarch - George Eliot
21. Gone With The Wind - Margaret Mitchell
22. The Great Gatsby - F Scott Fitzgerald
23. Bleak House - Charles Dickens
24. War and Peace - Leo Tolstoy
25. The Hitch Hiker’s Guide to the Galaxy - Douglas Adams
26. Brideshead Revisited – Evelyn Waugh
27. Crime and Punishment - Fyodor Dostoyevsky
28. Grapes of Wrath - John Steinbeck (one of the few Steinbeck's I haven't read)
29. Alice in Wonderland - Lewis Carroll
30 . The Wind in the Willows - Kenneth Grahame
31. Anna Karenina - Leo Tolstoy
32. David Copperfield – Charles Dickens
33. Chronicles of Narnia - CS Lewis
34 . Emma - Jane Austen
35. Persuasion - Jane Austen
36. The Lion, The Witch and The Wardrobe - CS Lewis
37. The Kite Runner - Khaled Hosseini
38. Captain Corelli’s Mandolin - Louis De Bernieres
39. Memoirs of a Geisha - Arthur Golden
40. Winnie the Pooh - AA Milne
41. Animal Farm - George Orwell
42. The Da Vinci Code - Dan Brown
43. One Hundred Years of Solitude - Gabriel Garcia Marquez
44. A Prayer for Owen Meaney - John Irving
45. The Woman in White - Wilkie Collins
46. Anne of Green Gables - LM Montgomery
47. Far From The Madding Crowd - Thomas Hardy
48. The Handmaid’s Tale - Margaret Atwood
49. Lord of the Flies – William Golding
50. Atonement - Ian McEwan
51. Life of Pi - Yann Martel
52. Dune- Frank Herbert
53. Cold Comfort Farm - Stella Gibbons
54. Sense and Sensibility - Jane Austen
55. A Suitable Boy - Vikram Seth
56. The Shadow of the Wind - Carlos Ruiz Zafon
57. A Tale Of Two Cities - Charles Dickens
59. The Curious Incident of the Dog in the Night-time - Mark Haddon
60. Love In The Time Of Cholera - Gabriel Garcia Marquez
61. Of Mice and Men - John Steinbeck
62. Lolita - Vladimir Nabokov
63. The Secret History - Donna Tartt
64. The Lovely Bones - Alice Sebold
65. Count of Monte Cristo - Alexandre Dumas
66. On The Road - Jack Kerouac
67. Jude the Obscure - Thomas Hardy
68. Bridget Jones’s Diary - Helen Fielding
69. Midnight’s Children - Salman Rushdie
70. Moby Dick – Herman Melville
71. Oliver Twist - Charles Dickens
72. Dracula - Bram Stoker
73. The Secret Garden - Frances Hodgson Burnett
74. Notes From A Small Island - Bill Bryson
75. Ulysses - James Joyce
76. The Bell Jar - Sylvia Plath
77. Swallows and Amazons
78. Germinal - Emile Zola
79. Vanity Fair - William Makepeace Thackeray
80. Possession - AS Byatt
81. A Christmas Carol - Charles Dickens
82 Cloud Atlas - David Mitchell
83. The Color Purple - Alice Walker
84. The Remains of the Day - Kazuo Ishiguro
85. Madame Bovary - Gustave Flaubert
86. A Fine Balance - Rohinton Mistry
87. Charlotte’s Web - EB White
88. The Five People You Meet In Heaven – Mitch Albom
89. Adventures of Sherlock Holmes - Sir Arthur Conan Doyle
90. The Faraway Tree Collection – Enid Blyton
91. Heart of Darkness - Joseph Conrad
92. The Little Prince – Antoine de St. Exupery
93. The Wasp Factory – Iain Banks
94. Watership Down - Richard Adams
95. A Confederacy of Dunces – John Kennedy Toole
96. A Town like Alice- Nevil Shute
97. The Three Musketeers - Alexandre Dumas
98. Hamlet- William Shakespeare
99. Charlie and the Chocolate Factory - Roald Dahl
100. Les Miserables – Victor Hugo
I would also suggest:
Angel of Repose by Wallace Stegner
You Can't Go Home Again by Thomas Wolfe
Out of Africa by Isak Dinesen
Midwives by Chris Bohjalian
Mountain Time by Ivan Doig
Ramona by Helen Hunt Jackson
Tony Hillerman's mysteries (featuring Chee and Leaphorn)
Linda Barnes mysteries (featuring Boston PI Carlotta Carlyle)
Stephen White's mysteries (featuring psychologist Dr Alan Gregory)
Susuan Wittig Albert's mysteries (featuring China Bayles, owner of a herbal shop)
Would welcome any suggestions for myself or to give to my nieces and nephews (ages 2 yo to mid-30's).

SurgeXperiences 203 -- Call for Submissions

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

Bongi, other things amanzi, will be your host for the next edition of the second season of SurgeXperiences (Sunday, August 3rd). He has no theme planned, so just write some surgery related posts and send them his way (here).
SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The deadline for submissions will be midnight on Friday, August 1st. Please submit your posts here.
Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Friday, July 25, 2008

Memory Quilt #5

I was only asked to make three quilts from all those shirts--one for each son, but I made four so the widow would have one. Then there were all those remaining squares from the car-fabric shirt and I couldn't resist making one more using them. This time around, I limited the different shirt fabrics to only three and did a modified-nine patch. Then to make it large enough, I added some left-over (from this project) flannel that makes you think of hunting/outdoors. Besides cars, hunting was a favorite pastime of the deceased. This quilt is 48 in X 68 in.

The quilt is machine pieced and quilted. The back fabric is the Route 66 fabric. Here is a close up that show one of the patches the family wanted added to the quilts.

Thursday, July 24, 2008

Behavior of Surgeons

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

Did you happen to see this news article? It reported on the orthopedic surgeon who gave his patient (female) a temporary tattoo as he put it "to lighten their spirits". I ran this by the crew I worked with in the OR this morning and didn't give them all the details, just this:
"Did you guys hear the news report of the orthopedic surgeon who did a lumbar procedure on a woman and then put a temporary tattoo on her lower abdomen, in the panty region? The patient found it when she went to get dressed in front of her husband. She was reportedly very emotionally traumatized by it."
All of them had somehow missed this news item. Questions came.
"Did he know this person? I mean were they friends outside of the professional relationship?"
"Was the surgeon and patient joking about tattoos in the pre-op?"
"How much is she suing for?"
"The other members of the OR crew allowed him to do this?!"
In the end we all agreed that this was not appropriate for the surgeon to do. My crew would have felt comfortable to have pointed this out to me (had I foolishly tried to do such a thing).
I do not in any terms want to "justify" this behavior, but neither do I think that what these two blog sites and their commenters (here and here) are doing with this incident is appropriate either. It is unfair to "lump" all physicians or all surgeons in a group with this one.
I ran across a post on "A Doctor's Touch" yesterday. It is worth reading the entire posts and it's comments. I think that most of us physicians/surgeons try to do just this with both "touch" and "interaction".
In conclusion, as you can see, a doctor’s touch is an action which, if used wisely and professionally can provide a variety of benefits from psychological to diagnostic. Also, you can see that touch is missing when the doctor-patient relationship involves phone, video or e-mail communication. It is understandable why we who teach medical students stress touch as an important medical tool in its many ways. ..Maurice.
It's the wisely and more importantly the professionally that stands out for me in the above paragraph. I try to keep things professional. I try to treat each patient with respect. Read these wonderful blogs by fellow surgeons and you will quickly see that many of us are in awe that patients place their trust in us.
other things amanzi
Reflections in a Head Mirror
Buckeye Surgeon
Someonetc (an orthopedic attending)

Breast Masses in Adolescent Girls

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

Breast masses in adolescent girls are usually benign.
  • is the most common discrete breast mass in the adolescent female (70%).
  • As many as 15% of patients may have multiple fibroadenomas.
  • On examination, these masses are smooth, mobile, and round.
  • They may occasionally become larger just before the patient's menstrual period.
  • They are well-circumscribed lesions that can be enucleated from the surrounding tissue at surgery. A true capsule is not typically present.
  • If the mass has the characteristics of a fibroadenoma, then it may be monitored with repeated careful physical examination every 1-3 months. Alternatively, an excisional biopsy may be performed if the patient and family request it.
Juvenile, or giant, Fibroadenomas
  • are unusually large (>5 cm) and are termed giant when greater than 8 cm.
  • The rapid increase in size is what usually brings the patient in to be seen.
  • They are benign, do not appear to become malignant or to be familial.
  • Management consists of surgery. Histologically, juvenile fibroadenomas have more cellularity than typical fibroadenomas. They should be differentiated from cystosarcoma phyllodes.
Cystosarcoma phyllodes tumors
  • manifest as a painless breast mass. Most occur later in life (the third or fourth decade).
  • Often the patient will have a history of sudden enlargement of a previously stable mass. The mass may be dramatically large; thinning of overlying skin and increased vascularity of the area may be present.
  • Ultrasonography cannot usually be used to distinguish between a fibroadenoma and a phyllodes tumor. That differentiation lies in histologic examination. Phyllodes tumors have a more cellular stroma with nuclear atypia and mitotic figures.
  • Usually quoted as 90% benign and 10% malignant. There are reports that state as many as 25% of phyllodes tumors may be considered malignant.
  • The management for either benign or malignant phyllodes tumor is wide excision with a margin of normal breast tissue. Malignant phyllodes tumors rarely metastasize to the axilla. Axillary dissections are indicated for patients with palpable lymph nodes.
Pseudoangiomatous Stromal Hyperplasia (PASH)
  • is a rare type of benign mesenchymal proliferative disease of the breast.
  • Histologically, it is composed of a proliferation of spindle cells with inter-anastomosing vascular-like arrangement in the interlobular or interductal stroma.
  • Clinically, PASH is usually found in premenopausal women as a discrete, painless mass, which is firm and movable.
Trauma to the breast, iatrogenic or blunt, may result in a palpable mass.
  • The trauma can cause fat necrosis, or breakdown of the adipose tissue. This can lead to a "mass" of scar tissue.
  • To complicate the diagnosis, women may or may not recall the inciting event. In addition, women may examine a traumatized breast and discover a mass that was present prior to the event.
  • Upon physical examination, the mass is sometimes indistinguishable from a cancer. Ultrasonography, mammography, and even MRI of the breast may not be able to discern the difference, leading to biopsies in concerning masses.
  • Key radiologic features (thought of as pathognomonic for) of fat necrosis include peripheral calcifications, fibrotic scar, and echogenic internal bands. However, these may also be consistent with breast cancer. Findings of lipid cysts or ultrasonographic evidence of fat necrosis may assist in the decision to monitor a palpable abnormality or perform a biopsy.
Fibrocystic changes of the breast
  • are very common in the adolescent population. Physical examination findings may reveal discrete breast cysts or diffuse small lumps throughout.
  • Breast tenderness and heaviness may be experienced by the patient, especially before her menstrual period.
  • The patient is advised to avoid caffeine. Evening primrose oil (1 tablespoon at bedtime) may be used to alleviate breast pain associated with fibrocystic changes of the breast.
  • A single dominant lump that is present for several months likely requires excisional biopsy.
  • Single dominant cysts may be aspirated in an outpatient setting. Cytopathologic examination should be conducted if the fluid is bloody.
  • Fibrocystic changes are histologically classified into 3 categories: nonproliferative changes, proliferative changes without atypia, and proliferative changes with atypia. Patients with proliferative changes and/or atypia have a higher risk for future malignancies.
  • There is no specific data available in adolescents that would describe their risk of developing breast cancer. It is well described in adults.
  1. There is a 1.5-2 fold increase in women with proliferative fibrocystic disease (described histologically as moderate or florid hyperplasia, sclerosing adenosis, or papilloma with a fibrovascular core).
  2. There is a 4.4 fold increase in patients with atypical or lobular hyperplasia. This risk increase to 9 fold with a positive family history.
  3. Screening guidelines for patients with a history of atypia on breast biopsy findings are still evolving. In adults, current recommendations include yearly physician examinations and yearly mammography.
Malignant breast disease is uncommon in children and in adolescents. Risk factors for breast malignancies include history of familial breast cancer, previous benign disease associated with malignancy (ie, fibrocystic changes with atypia), other malignancies, or irradiation to the neck and chest areas. The most common malignant mass in the breast of a child or adolescent is a metastatic lesion.
Cautionary Note: In very young and preadolescent children, a biopsy should be considered with extreme caution because the developing breast bud may be irreparably harmed, even with a needle aspirate. That said, discrete masses should almost always be removed regardless of age.
Disorders of the Breast; eMedicine Article, Jan 24, 2008; Margorie J Arca, MD and Denise B Klinkner MD
What is this Girl's Rapidly Enlarging Breast Mass? How we diagnosed and treated a juvenile fibroadenoma; Contemporary Surgery Vol 64, No 7, pp 328-331; Sheetal M Patel MD and Matthew J Hyser MD
Pseudoangiomatous Stromal Hyperplasia of the Breast in Two Adolescent Females; Am Surg 2004; 70(7):605-8; Gow KW, Mayfield JK, Lloyd D, Shehata BM (abstract)
Breast, Fibroadenoma; eMedicine Article, Feb 16, 2007; Marilyn A Roubidoux MD
Cystosarcoma Phyllodes; eMedicine Article, June 12, 2006; Donald R Lannin MD and Anastasios K Konstantakoes MD, John H Raaf MD
Pseudoangiomatous Stromal Hyperplasia Tumor: a Clinical, Radiologic, and Pathologic Study of 26 Cases; Mod Pathol 2008; 21(2):201-7; Ferreira M; Albarracin CT (abstract)
Fast-growing Pseudoangiomatous Stromal Hyperplasia of the Breast: Report of a Case; Surg Today 2007; 37(11): 967-70; Yoo K; Woo OH; Yong HS; Kim A; Ryu WS; Koo BH; Kang EY (abstract)

Wednesday, July 23, 2008

The Blalock-Taussig-Thomas Collaboration

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

JAMA (Journal of American Medical Association) is celebrating 125 years of history. In a recent issue, there was a very nice article on an historic surgical procedure: The Blalock-Taussig-Thomas Collaboration, A Model for Medical Progress. As I wasn't "logged in" when I viewed both of the articles (recent and original), I think anyone interested in reading the full articles will be able to do so.
The Surgical Treatment of Malformations of the Heart in Which There Is Pulmonary Stenosis or Pulmonary Atresia
Alfred Blalock, MD; Helen B. Taussig, MD
JAMA. 1945;128(3):189-202
Heretofore there has been no satisfactory treatment for pulmonary stenosis and pulmonary atresia. A "blue" baby with a malformed heart was considered beyond the reach of surgical aid. During the past three months we have operated on 3 children with severe degrees of pulmonary stenosis and each of the patients appears to be greatly benefited. In the second and third cases, in which there was deep persistent cyanosis, the cyanosis has greatly diminished or has disappeared and the general condition of the patients is proportionally improved. The results are sufficiently encouraging to warrant an early report.
The operation here reported and the studies leading thereto were undertaken with the conviction that even though the structure of the heart was grossly abnormal, in many instances it might be possible to alter the course of the circulation in such a manner as to lessen the cyanosis and the resultant disability. It is important to emphasize the fact that it is not the cyanosis, per se, which does harm. Nevertheless, since cyanosis is a striking manifestation of the underlying anoxemia and the compensatory polycythemia, a brief discussion of the causes of cyanosis and the factors operative in congenital malformations of the heart is essential in order to understand the principles underlying the present operation.
At the time the classic study of Alfred Blalock and Helen Taussig was published in 1945, the care of patients with cyanotic congenital heart disease was an exercise in clinical-pathologic correlation, rather than care with therapeutic hope. Historically it occurred at a time when the Johns Hopkins Hospital had racially segregated wards, and women were rarely appointed to medical school faculty. As a result of the publication of this study, an era of cardiac surgical intervention blossomed, and the field of pediatric cardiology rose to prominence as a subspecialty in pediatrics. The work also served as a model for bench to bedside investigation and later became a catalyst to address historical injustices in medicine.
The most common congenital heart defect associated with cyanosis is tetralogy of Fallot. This lesion consists of a defect in the ventricular septum that lies below an aorta that is dextroposed and thus overrides the defect, obstruction to pulmonary blood flow, and right ventricular hypertrophy that is secondary to pressure overload. The authors clearly stated their view that the fundamental cause for cyanosis in this type of defect and the more severe variant with pulmonary atresia was a decrease in blood flow to the pulmonary arterial bed. As a previous commentary about this article noted, this pathophysiologic mechanism was by no means generally accepted at the time. The clinical observations of Taussig that infants with pulmonary atresia would often die of profound hypoxemia when the ductus arteriosus spontaneously closed led to the hypothesis that providing additional pulmonary blood flow, by connecting a systemic artery to the pulmonary artery, would alleviate cyanosis. This concept was tested in Blalock's surgical laboratory; although they were unsuccessful in creating a model with pulmonary stenosis and cyanosis, a model with partial lung resection and creation of pulmonary arteriovenous fistulae sufficed to reproduce the right to left shunt and decreased pulmonary blood flow. Using this animal model Blalock's team demonstrated that anastomosis of a systemic artery to the pulmonary artery was feasible and improved the arterial oxygen saturation..............
Cooperation Across Disciplines

The Blalock-Taussig article foreshadowed areas of progress in medicine by providing a model for cooperation across disciplines to make striking medical progress. The surgical treatment of patients with cyanotic congenital heart disease began as collaboration between pediatric cardiologist, cardiac surgeon, and anesthesiologist as described in the article by Blalock and Taussig. To this day the interdependence and collaboration of these specialties remain the model. Perhaps more remarkable was the prominent role of Taussig, who later became the second female full professor at Johns Hopkins. Taussig was able to attend the Johns Hopkins University School of Medicine because of the legacy of female philanthropists, including Mary Elizabeth Garrett and M. Carey Thomas, who endowed the school with the stipulation that women be admitted as students on the same basis as men.
Tragically, however, the authors of this classic article did not acknowledge a key individual in the work. The silent partner was Vivien Thomas, an African American man and Blalock's surgical technician, who helped develop the subclavian to pulmonary anastomosis in the animal laboratory. Indeed his role was of such vital importance that he attended the early operations and is captured in a photograph standing behind Blalock in the operating room. The remarkable contributions of this man have been detailed in the recent HBO movie Something the Lord Made and the earlier PBS documentary Partners of the Heart. Thomas was ultimately recognized by the institution he served so well, first by the commission of a portrait that is displayed near that of his mentor Blalock, and later by the awarding of an honorary doctoral degree. Today 1 of the 4 advisory colleges for medical students at Johns Hopkins is named for Thomas, and the story of his role in this surgery is explained to every entering class.
The Blalock-Taussig-Thomas Collaboration, A Model for Medical Progress; Commentary by Anne M. Murphy, MD; Duke E. Cameron, MD; JAMA. 2008;300(3):328-330.
The Surgical Treatment of Malformations of the Heart in Which There Is Pulmonary Stenosis or Pulmonary Atresia; Alfred Blalock, MD; Helen B. Taussig, MD; JAMA. 1945;128(3):189-202

Tuesday, July 22, 2008

GruntDoc Hosts Grand Rounds 4:44

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.
GruntDoc hosts Grand Rounds for the 6th time! This week's edition just happens to be the 200th edition!!! Check it out here.
I’m Honored to be the first Sixth Time Host, but more importantly to be the host of the 200th Edition of MedBlogs Grand Rounds. Dr. Nick Genes deserves all the credit for starting (and maintaining) this wandering collection of links to the best of the MedBlogosphere (thanks, Nick!).
There were more than 40 submissions this week, and here they are in the order they were received, (with my ER Doc attention span review in parenthesis at the end of the link)

Monday, July 21, 2008


My friend's dad died this past Thursday. His death was not unexpected, as he had severe Parkinson's Disease (previous post). I have known this family for nearly 40 years now. My friend and I have been friends since we both moved to Vilonia in the fourth grade. Her mother taught business classes there. We took her typing class.

My friend lives in Rowlett, TX and was due to arrive at her parent's home Saturday afternoon. So I drove up to visit with her and her family. I beat my friend by a few hours. I ended up spending several hours there, watching people come and go. Mrs. R and I were the only two there for an hour or so. Her words "I'm going to go to the back room and make some more calls. I don't feel bad about leaving you in here alone, because you're family. You know what I mean?" She left me to make some calls for her to local hotels asking about rates for out-of-town family and friends.

I was struck by all the food that visitors brought. I was enlisted to help put some of it into zip-lock bags or other containers so that it could be frozen. We cleared the kitchen counter of pies, cakes, rolls, and casseroles that would freeze. They told me they had already done this once. And yet with the next wave of folks, more food came. The counters quickly filled up again.

I didn't take food. I had read somewhere about 5 years ago (Hints for Heloise or Ann Landers) that families with illness or deaths in the family often needed supplies/staples. It listed items like toilet paper, paper towels, paper plates/utensils, Kleenexes, coffee/creamer, note cards with stamps, etc. So that is what I have begun to do.

Mrs R encouraged all her visitors (would-be-comforters) to eat. Then she would try to get them to fix themselves a plate or two of food to take home. Part of this was simply her good nature of caring for folks. Even in this time of her grief, she was trying to take care of others. Part of it was as she explained, the need to reduce the food in the house. The family was feeling overwhelmed by the food and didn't want it to be wasted or go bad before they could eat it. Yet they were running out of freezer space. Mrs R at one point asked "Why do they all feel they need to bring us food?"

Here in the south, that seems to be the way we are raised. Funerals and the family visitations seem to be a time of feeding and by extension eating. Food is very much associated with comfort. We don't seem to be able to just go and sit and listen and tell stories and share photos/memories without taking something to the family. We want to "feed" them as a way of trying to ease "this difficult time". I would have felt "guilty" or as if I had let my own mother down if I had not taken something. But I think for my friends, they would have been happy for me just to have come as I did and spent time.

It felt funny to me to leave with a plate of food, but it made Mrs R feel better. She wanted me to take two or three plates.

Sunday, July 20, 2008

SurgeXperience 202

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

Since the last edition, there has been the death of a surgery pioneer -- Dr. Michael E DeBakey (1908-2008). I wrote a post on him last year. There were many mentions of him this past week. Here are the ones I ran across.
Michael E. DeBakey: Pioneering Surgeon, Educator & Inventor
Thank You, Dr. Michael DeBakey (NPR's Science Friday) -- has a link to a 1993 interview they did with Dr. DeBakey.
Michael DeBakey, 1908-2008 from Dr Reese, Medinnovationblog
Pioneering Heart Surgeon -- Washington Post Obituary
Michael E DeBakey, 1908-2008 -- Scrub Notes, Sketches from a Med Student's Brain
Excursions in Medical History: In Memoriam Michael Ellis DeBakey, Sept 7, 1908 - July 11, 2008 by T (Notes of an Anesthesioboist)
Remembering a Medical Legend, with Gratitude by Dr Sanjay Gupta; July 18, 2008
Surgical Giant by Buckeye Surgeon
Some Debakey quotes:
"Man was born to work hard"
"Once you excise the skin, you find they are all very similar"
"I like my work very much. I like it so much I don't want to do anything else."
RIP, Dr DeBakey....

Aggravated DocSurg writes a moving tribute to a patient in Sara's Smile.
The day I first met her is one not easily forgotten. A new patient on my schedule, I knew nothing of her past; there was just a note requesting a cervical lymph node biopsy. I was greeted with a warm hello and a welcoming smile.

Then there is the message you hope never to send (or receive). Paul Levy talks about it (and then follows up here).
Before I start, I want to refer you to an excellent story summarizing the case written by Stephen Smith at the Boston Globe.
So, here are a few things you might want to know. The things that went wrong are summarized above and simply should not have happened. The test for our place is to figure out how to make the right things happen 100% of the time. As we work on that, I'll keep you informed.

Buckeye Surgeon that looks at disclosure and honest in discussing surgical errors that occur with patients in his post "tangled up in blue".
Why did the kidney fail? I asked.
-When they were doing my hysterectomy, the "urether" got tangled up in some adhesions, she said.
-When was the hysterectomy?
-Oh lord, maybe 30 years ago.
-I see.
-They had to go back in and try to untangle it a few days later, but the kidney died anyway, she said.

Bongi, other things amanzi, gives us another glimpse into life of the surgeon and patient in his recent post captive
the next morning the patient wasn't only alive, but he was doing very well. he was still on a ventilator, but we expected to wean him in a day or two.
then two cops walked in carrying a ridiculous amount of heavy chains and shackles. they walked up to my patient and sort of dumped them on the bed with a loud clang. they then told me they were going to chain him down.
and in this post family
it was the usual story and i didn't think too much of it until the next morning....... the patient's mother came in to see how he was. i have treated numerous criminals, but this was a first. i found it interesting so i decided to chat to her to find out where such a criminal comes from.
the first thing she told me is that she was a theater sister and worked night shift in a local hospital. this took me totally by surprise. firstly i wanted to believe that my patient came from a broken home or had some similar pathology in his past. but more importantly, a theater sister is like family to me. i have spent countless nights across an open abdomen with theater sisters.

Buckeye Surgeon had two posts that I think go together--Bowel Obstruction (photo from his post) and Internal Hernia.
Well, I saw a lady last week with a classic SBO on initial imaging. A year and a half ago, she had undergone a laparoscopic right hemicolectomy for a villous adenoma at a "major midwestern university program". I put an NG in but she didn't get better.

Dr Michael O'Connor, The Ether Way, in his post on Evil Humors writes about attending M&M conferences.
As an educator, one of my greatest responsibilities is this: to convey to my students, residents, and fellows an appropriate degree of circumspection regarding the limits of our knowledge and understanding.
‘I know what happened.’ Bullshit.
One of the wisest men I have ever met says: ‘ I don’t know what it was, but whatever it was, it was the worst case of it I ever saw.’
As for me, I know: it’s syphilis.

QuietusLeo, The Sandman, writes about a night on call in The "eyes" have it.
A 51 year old semi-conscious man was brought in. Full of shrapnel holes, right leg broken, a finger or two mangled, left eye looks like mush, pools of blood forming around him and most importantly an expanding hematoma in the neck.

Dr Bruce Campbell, Reflections in a Head Mirror, talks about distractions in a recent post
Difficulties increase the nearer we get to the goal.”-Goethe
Have you ever noticed this, as well?
and about how some patients are just Boneheaded.

Someonetc, our orthopedic attending, tries to show by example how to be a good doctor in I am the boss of me.
Today, I sit in my office after 7 waiting for a case and I am not on call. Why? I feel it is the right thing to do for the patient. On the other hand, my all of resident have gone home. I guess I can't expect that they too would feel the need to stay, but I can still hope.
So, I continue to model.

Dr B, Surgery....Passionately, writes about telling a patient that you disagree with the previous doctor in her post, Prove It.
One of the hardest things, I think, in medical practice, is attempting to prove to a patient that you (as a specialist) are in the right, when, in fact another surgeon in your specialty has proven some other thing to said patient. (still with me?)

David Gorski, Science-Based Medicine, wrote about a death by "alternative" medicine and asks who's to blame?
This patient was in serious trouble. You would think that, finally–finally–she would have realized her mistake in not having gone with surgery and conventional medicine.
You would be mistaken.
The patient still steadfastly refused all surgery, chemotherapy, and radiation. Against all evidence that the course she had chosen thus far had not resulted in the elimination of her tumor that she expected, she nonetheless insisted on continuing with various alternative medicine treatments. Against all evidence to the contrary, she continued to refuse any form of “conventional medicine.” She still believed that her ” healer” could save her life, even though she now had a large, bleeding, stinking mass in her breast stuck to her chest wall that had three years ago been a pea-sized cancer that could have easily been excised with a small surgical procedure.

Dr Au, the Underwear Drawer, writes about her last day as a resident (she's now an attending anesthesiologist in Atlanta-- congratulations) in her post "a fitting end"
How fitting, really, to do a heart transplant as one’s last case of residency. Much like the process of medical training, an organ transplant takes the ordinary and transposes it into extraordinary circumstances—in this case, taking the heart of a freshly deceased patient and having it work in the body of a patient who still might be saved. The recipient that day was a 57 year-old man with dilated cardiomyopathy................... The patient's old heart was huge, congested, an angry and mottled looking purplish mass looking more like a dead thing in a butcher’s window than anything else. We worked together to get the patient onto cardiopulmonary bypass, the surgeons snipped the old heart out, and suddenly the chest cavity was huge, empty, a yawning expanse waiting to be filled.

Dr Oliver, Plastic Surgery 101, has a very nice post on "What's Oncoplastic Surgery?"
This is conceptually just lumpectomy or mastectomy done better. The concept uses rotating breast tissue to fill defects at the time of lumpectomy or larger "quadrantectomy" procedures. These are maneuvers we use with breast reduction and mastopexy procedures adapted to some of the cancer surgery procedures.

How about appendicitis in pregnancy? Check this out at Radiology Picture of the Day (credit)

KeaGirl, UroStream, wants to remind patients that ALL of your medical history is important in her post not so insignificant.
I am always astounded at the details that patients omit on their medical history form. I'm clued in when I look at their medication list and see 3 different antihypertensive medications, yet they don't list hypertension as one of their medical condition. Usually the explanation is something like: "but with the meds, I don't have high blood pressure anymore....

Dr Val writes about living with faces that are very different from those around you in Saving Face: Kiddies and Kitties.
What struck me about the girl's story was how she described how it felt to be teased growing up, and how the worst part of the teasing was that no one stuck up for her. I've seen kids do this kind of thing before, and I can imagine how painful it is when no one has the courage to go to bat for you.

White Coat Rants shares a practical tip from a patient (photo credit) or another use for duct tape in his post, "It's Like the Force -- Only Better".

Happy Hospitalist shares his uncle's experience with surgery in Egypt.
My parents flew to Egypt to be with my Uncle Maher for an elective total knee arthroplasty. This is my mother's diary of observations:
June 19th--Again the airline Gods willing, we will get on a Delta flight that leaves JFK at 4:20 on Tuesday, June 24 and arrive in Cairo at 10:35 am on Wednesday, June 25. That is, if all goes according to plans. Maher's surgery is scheduled for July 5, so we are getting there earlier than necessary, but .....

Here is the first X-ray (credit) from a series that Dr Shroom, The Knife Man, did recently. Begin here with his post The Missing X-rays of Uncle Shroom, then go to Mea Culp Part 2, Mea Maxima Culp, and then the Finale.
Part of the 'mea culpa' series. Hopefully, a very occasional series. In several parts.

With the new iPhone released recently, Mark Borkowski writes:
I have been approached by a UK plastic surgeon who wants to discuss publicizing his new treatment. The phone call was a bit of a long ramble but essentially he wants to be the first British practitioner to surgically alter thumbs to make using an iPhone easier. I hope he is not a prankster reacting to this post.

IntraopOrate has begun a series of posts that tell the tale of how she became a surgical assistant and got to this point "meanwhile back at the ranch"
It started Sunday afternoon while he was on ER call, which means general surgical cases from the ER are referred to him. First case, a perfed (perforated) viscus at the jejunum. Fairly straightforward repair with a patch of omentum thrown over the top for added strength and healing power. He complimented me on having quiet hands. I was flattered.
Drnjbmd, Medicine from the Trenches, writes about why he chose surgery as his profession:
I was hooked on Surgery from my first case. It was a total colectomy with four females operating. My chief resident was female, the junior resident was female, the attending was female and I was female. We talked about shoes and Chanel suits during the case. I tied tons of knots and helped the junior resident close the incision. It was heaven. I found out that I loved Trauma and I couldn't wait to be on call every third day. I had the time of my life and I loved everything about surgery.
I'm not sure if this is a picture (credit) of T, Notes of an Anesthesioboist, or whether she is just getting prepared to look a patient in the mouth (what's that about?).
"I feel pretty,
Oh, so pretty,
I feel pretty and witty and bright!
And I pity
Any girl who isn't me tonight..."
But don't worry, T (and her fellow surgeon) will sing to you to put you at ease. Check out this post on "Songs in the OR"
Then, a little louder, "But somewhere in my wicked, miserable past there must have been a moment of truth." Dr. Warbucks, though feeling a little impatient over the delay with the blood pressure cuff, had gotten into the Rodgers and Hammerstein spirit.
As I secured the LMA into place, he stood up, put on his x-ray apron, and belted in my direction, "For here you are, standing there, loving me, whether or not you should!"
So I replied, and we finished together, "So somewhere in my youth or childhood, I must have done something good."
Sterile Eye may be on break to enjoy the summer outdoors with his kids, but he left us some amazing videos of sarcoma surgery. If you haven't seen them, here's the link.

If you like learning by watching videos, then check out these presented by ORLive:
Innovations in Stroke Prevention: An Update in Carotid Stenting presented by William A Gray MD, Y Pierre Gobin MD, and James McKinsey MD; New York-Presbyterian Hospital, NYC, NY; July 15, 2008
Replay of Heart Transplant Procedure; Sept 19, 2007

Dr Alice, Cut on the Dotted Line, writes that urine is good. She is now a second year surgery resident.
I got to do my first transplant today.
More precisely, I assisted the attending for the first time today; but I have high hopes of getting to do more of the procedure later on. I really didn’t want to ask for anything more; I was still figuring out the anatomy (well, ok, so the external iliac artery and vein are not that complicated; but the way that the donor artery, vein, and ureter fit in is), and I don’t have much experience sewing blood vessels yet.

Theresa, Rural Doctoring, is a hospitalist in rural California. She tells a story of being asked to do a pre-operative clearance on an orthopedic surgeon. You'll have to read the post for the punch-line.
One day I was trying to get ready to go to the hospital when I got a page. It was one of the orthopedic surgeons asking me to consult on a patient.
"The nurses called me and they're freaking out," said the orthopod. "The guy threw up red stuff and they're afraid he's got a GI bleed. I'm supposed to take him to the OR at nine-thirty."

TC, Donorcycle, writes about the best call she ever made.
So there he is, going about his daily business, doing whatever with the missus and BANG! Drop everything, pack your toothpaste and jammies-you're going to the hospital for a new kidney! And I get to be the person who tells him it's Christmas, your birthday and the 4th of July all rolled into one.

Uveal Blues is an ex-USA-expat ophthalmologist with a strong interest in international healthcare. He gives us this post on Countries Make Push to Increase Eye Donors.
The non-acceptance of corneal transplantation in the third world continues to be a problem. It is encouraging to see that efforts to increase acceptance are being made in Syria. I should also acknowledge that Dr. David Paton, who started Orbis' Flying Eye Hospital, also started the first eye bank in the Middle East. (The article also quotes my friend, Dr. Hunter Cherwek, the current medical director of Orbis).

Plasticized gives us another example of the extreme alterations some people do to their bodies (photo from his post)

Our Next Generation of Surgeons/Anesthesiologists/etc:
Med Obsession My Life has officially begun 4th year orientation.
The first day was sooo fun. ..........Today, I did my first hysterectomy… on a cadaver!

Derrx, Silent River, writes about "The Junior Intership (12 months of REAL medical drama...) -- Part 2"
Surgery, probably the most diverse rotation of them all... when i say diverse, it's because of the different subrotations each has to go into. i dont exactly recall which rotations came first so i'll go with whatever comes to mind first. anyway, when i think of surgery, the first rotation i will remember would be that of Amang Rodriquez.

Dragonfly, The Dragonfly Initiative, writes in her post Orthopaedics for beginners
Orthopaedics is (so far) going better than expected. In one afternoon (joint replacements are not exactly quickies) I get to realise 2 of my childhood dreams - surgeon and astronaut. Now if only there was a way to be an life saving, space exploring prima ballerina....
and then in her post the hidden world of arthroscopy likens it to
Like taking a tour through an underwater cave .
On our left are fronds of seaweed/synovium, waving in the currents of irrigation fluid.

Jeffrey (Monash Medical Student) sent me this link to a cartoon (photo credit).

Ms Ellisa writes a great post about learning (and teaching) in My Airway.
He raises his hand and stops her.
He says:
"No. Not that. If you don't know the BASIC A-B-C-D's you will LOSE him, no matter what else you know"
And he turns to me, points at me with the same already raised hand, now in approval- the same in which he clutched her face in the dirt (okay okay I'll dial it down :) ) points at me and says - in words roughly translated because you can't find the exact translation in English -
"Say it baby!"
And I simply explained that "A", is "Airway", and you have to make sure he can breathe first, before doing anything else...

Some of our patients and their stories
Martha Watson gives us her side in "The juicy details of my hand surgery"
If you are planning to have bone surgery in your hands, it truly is incredibly painful. Immediately afterwards, it feels like you shut your finger hard in the car door, and just for kicks, did it again and maybe once more, to see if it couldn’t hurt any worse..........
My favorite type of anesthesia for hand surgery is the Bier Block, a combination of tourniquet and a local anesthesia (numbing shot). ........... You’d think a shot in the armpit would be horribly painful, but really it’s not at all. This surprised me the first time I had it done, as this was the thing I feared most about that operation................

A woman who lives in Florida writes about her experiences in My Brain Surgery
Angiograms are not fun. But it was very interesting that I had my own personal fireworks/laser show behind my eyes. I saw little flashes of light every time they injected the dye. The doctor said I was seeing the synapses of my brain firing. It was quite amazing. Sometimes at night when I close my eyes I can still see faint flashes. Weird huh? It has been three years since my surgery. There are some remaining after effects. I have diminished vision in my right eye. I lost memories. I lose my train of thought very easily. My mind goes blank just like a TV during a power outage in the middle of a movie.......

Molly's Trek (which all began with Strep Throat) is an incredible story of a simple sore throat that went on to wreck havoc with her health and her journey back. If you go back through the posts, you will find multiple surgeries (wound debridemont, skin grafts, amputations, hand surgeries) and now her therapy. Here is an excerpt from the most recent post after hand surgery:
For example, we know nerve regeneration continues in Molly's hands which is evident because she says she feels like she has better control and command of objects she is holding.

Pepe received a lung transplant on July 3, 2008. Posts since then indicate that she has had many postop complications, but hanging in there. This is from July 13, POD 11
She had a new X-ray that showed recession of her pneumonia in the lower lobes. She also had a second bronch in which the doctor cleared much of the mucus and took more biopsies that remained negative for rejection. All great news. Pepe is tired and in some pain but much more comfortable, breathing more easily despite a lingering "roughness" from the remaining infection. Her sat is up to 94 percent on 10 liters. Her PaCO2 has dropped dramatically, into the 40s, not far from normal.

What do you do when you are a patient who needs to use medical adhesives and are allergic to them? Well, it seems that Amy Tenderich, Diabetesmine, is unfortunately going to find out.
You’re the only one in the family who needs medical adhesives, and now you’re allergic to them. Isn’t that ironic or something?” my 11-year-old blurted out on the way home from the dermatologist late last week.

One of our fellow doctors who just happens to be a patient writes a blog called The Tale of My Left Foot. Read her take on being a cancer survivor.
Oh you're a cancer survivor that's incredible. To which I had to take pause.
Cancer survivor- not a label I apply to myself. The very term seems off to me. The whole concept of survivor is final- like there is a great battle and you survived it, or some natural disaster, or some other calamity...............

Some thought provoking posts (not necessarily surgical)
Amanzimtoti writes a thoughtful post on Third world aid.
We recently had an American delegation from PEPFAR (the United States President's emergency plan for AIDS relieve) visit our clinic. I didn't stick around for the circus because preceding the visit a list of demands was given to the clinical manager. Now PEPFAR isn't even one of our major sponsors - from what I understand the money they've given us was just enough to put up some shelves in our pharmacy. Don't get me wrong, we're grateful for any donations, but if you're going to give money for a worthy cause, you should do it out of the goodness of your heart, not so you can make them jump through hoops for you.

Dr. Shaheen Lakhan, Brain Blogger, submitted this thoughtful post, Ethical Obligations of Health Care Workers During a Pandemic
The romantic notion of selfless sacrifice in medicine may be the exception rather than the norm in the face of a global pandemic, which would stretch our already over-stretched resources to the breaking point. Although history has given us many noble figures in medicine, how noble will we be if we are faced with a highly virulent strain of flu to which none of us are immune, and to which a vaccine to prevent the illness might not be available until after the outbreak of the disease has already begun?

Is Death the Enemy? by Dr Jay, Missionary Doc in the Making
You know, death is an interesting event. As a physician in training it kind of feels like failure....
So now that I have set the morbid tone of my entry, :), my day actually started out with beginning of two new lives. Today, I assisted in a C-section where the mother was pregnant with twins…two beautiful baby girls............
After witnessing two new lives enter this world, I witnessed two leave it. As we were rounding on the male medical ward (which I noticed is composed of mostly HIV reactive patients) we were evaluating a patient who was experiencing dypsnea...........He looked at me and said, “Kaposi sarcoma“. There is nothing we could do; the sarcoma had infiltrated his lungs and progressed so far that you could see the vascular papules on his hard palate.

For any parent/surgeon/doctor, I hope your children might write this about you:
On behalf of children everywhere with doctor parents who worry, fret, and guilt themselves over the time they have to spend apart from their children...I want you to know that we love you, and even if it's hard when we're little to understand what you do, or why you're gone so long sometimes (though we tend to vaguely grasp even then the idea that "work" is very hard and busy and keeps you away even though you love us very much and wish all the time that you were here with us), we're proud of you and love you very much. We do our best to understand and accept these struggles with you, and we see better while looking back from older ages all of the sacrifices and difficulties you've endured for us, and just how much you've always loved us--and at all ages young to old, we love to hear you say it on nights when you're around to tuck us into bed. (read the entire post here)

How to Pick a Nursing Home for an Alzheimer's Patient to Pick a Nursing Home for an Alzheimer's Patient by Ray Mullman; July 14, 2008

Surgery in the News and on TV
If you get a chance to watch this episode of PBS' Wide Angle, I hope you will do so: Birth of a Surgeon, Midwives in Mozambique
The film Birth of a Surgeon follows Emilia Cumbane, one of the first midwives-in-training. She performs Cesareans and hysterectomies in makeshift operating rooms in rural Mozambique. We follow Cumbane from her home in the Mozambican capital Maputo, into intensive medical classes, through night shifts in the delivery wards, and watch as she fights for recognition of her surgical competence.

Coalition doctors remove tumor, save Afghan girl's life by Army Sgt. Daniel Love; Armed Force Link, July 15, 2008 (via Chris, Made a Difference)

Jeffrey, Monash Medical Student, gives a critique of the
Real Life Grey's Anatomy (Hopkins) and gives you this info:
You can even watch the episodes online for free.
Rise Seen in Medical Efforts to Treat the Very Old by Anemona Hartocollis; NYTimes, July 18, 2009 -- When is too old for surgery?

Doctor Gets 10 Years in Prison for Surgery Scam -- Surgeons like this make us all look bad.

Teen Nixed from Transplant List Because He’s a Foster Child -- Sadly, I can see why this rule exists. There has to be a support system of responsible care for the patient. There has to be someone responsible to make sure the anti-rejection drugs are taken as prescribed, make sure appointments are keep, etc. By putting it in the news, maybe a good Samaritan will come forward to "foster" this child.

Donor Kidneys Removed with Single Bellybutton Cut By Thomas J Sheeran; Associated Press, July 17, 2008 (commentary by Buckeye Surgeon here)

Costs, quality of life drive doctors from the baby business (via Kevin, MD)

Okay, folks, I went looking for a lot of these posts (I kind of enjoy doing this). Most were not submitted (as they are suppose to be). That said, please, SUBMIT your posts for the next edition of SurgeXperience here. The next edition will be published on Sunday, August 3. Deadline for submission is Friday August 1st. Our next host will be Bongi, Other Things Amanzi,who is much busier than I and most likely will not seek out your posts (no matter how good).

And Dr Schwab if you happen to still be reading blogs, we miss your writing. We miss you.
Thanks for allowing me to host this edition of SurgeXperiences. Hope you'll visit all the blogs. Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Saturday, July 19, 2008

And the Bag Goes To

Last Friday, I posted the offer of this quilter's bag. Well of the two who left a comment, I've drawn Anne's name. So Anne if you'll e-mail with your address, I'll send you the bag. It's really very nice.

Friday, July 18, 2008

Memory Quilt #4

Here is the fourth memory quilt made from the shirts. This one is 50 in X 70 in, machine pieced and quilted.
Here is a detail view. You can see the razorback patch that I was given to add. He was a big fan of the Arkansas Razorbacks.

You can see the first three quilts here, here, and here. This one also has the Route 66 fabric for the backing.

Thursday, July 17, 2008

The Birth of a Surgeon

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

I watched this episode of Wide Angle, The Birth of a Surgeon, Midwives in Mozambique, on my local PBS station earlier this week. If you get a chance to watch it, do so. It covers the topic of maternal death in Sub-Saharan Africa and the countries effort to change it. It is well worth your time to watch.
Sub-Saharan Africa is the world’s deadliest place to give birth. Each year over a quarter of a million women die in childbirth in the region. But Mozambique is combating high maternal death rates by implementing unconventional programs.
After the country declared its independence from 400 years of Portuguese rule in 1975, a civil war raged for 16 years, killing a million people and wrecking the country’s infrastructure. By the time the war ended in 1992, the health care system was devastated and one in ten women were dying in childbirth. There were only 18 obstetricians for a population of 19 million. Since then, Mozambique has cut the maternal death rate in half.
As the figures now stand, the country is one of the few countries on track to achieve the fifth United Nations Millennium Development goal to reduce the maternal death rate by 75 percent by 2015. In 2004, Mozambique introduced a new health care initiative to train midwives in emergency obstetric care in an attempt to guarantee access to quality medical care during pregnancy and childbirth.

Snake Bites

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

I couple of weeks ago when walking my dog early one Sunday morning, we came upon a snake with another snake in its mouth (similar to this). I was left wishing I'd had my camera with me. Then earlier this week on Twitter, there was quite a discussion going on after Theresa admitted a patient with a rattle snake bite. So I thought I would re-post my June 7, 2007 post on Snake Bites. Here it is
I found this under my patio table in the backyard yesterday. Yikes! I really don't like snakes, but can deal with them when necessary. Fortunately, my husband was home. So he dealt with the snake (It's a good snake, says he.) while I took the dogs for a walk. It turns out he was right. The snake is a Eastern Hognose Snake (Heterodon platirhinos). In Arkansas, our poisionous snakes include Copperhead / Pigmy Rattlesnake, Cottonmouth, Timber Rattlesnake / Coral Snake, Western Diamondback Rattlesnake. Comparative risks tables place the annual death from drownings at more than 6,000 and the annual deaths from snake bites at 5.5.

There is a very nice review article of snake bites (Bites and Stings: Snake Bites) at Medscape. First Aid in the field (or home) consists of:
  1. Preventing systemic absorption of the toxin which may be done with compressive dressings and immobilization of the bitten extremity.
  2. If signs of envenomation begin to occur, a constriction band to impede lymphatic flow should be placed on the extremity, proximal to the bite. Transport to a hospital should take place immediately.

  3. The site should be wiped off and cleaned. The use of field first-aid methods such as incision and suction, tourniquets, and cryotherapy has been associated with a threefold increase in the likelihood of the need for surgical intervention.
  4. Although popular belief has it that snakebites kill within minutes, in fact, the toxicity from snake venom usually does not even begin to affect the body for several hours. In one review, 64% of deaths from snakebite occurred between 6 and 48 hours after the patient was bitten.
I have never in my years of practice had to deal with a snake bite, but have a healthy fear of cotton mouths and copper heads. I know that snakes may be an important part of our environment, but I still don't like snakes.
Have a safe summer enjoying the outdoors!

Wednesday, July 16, 2008

Major and Lethal Complications of Liposuction -- An Article Review

I would like to begin this post by saying that I think liposuction is safe when done under the proper conditions by a trained surgeon and for the correct patient. So for all you non-medical types, if you continue to read this, please keep that in mind. I also feel that it is important for anyone who tries to improve their skills/knowledge to be willing to look at outcomes (good and bad) and assess them critically.

The first article referenced below was written by German surgeons and is the article I am reviewing here. Apparently their patients, like the ones in America, feel that liposuction is a minor surgery. Their opening comments could easily apply here in the United States.

The number of aesthetic surgical procedures performed in Germany is increasing rapidly. In 2003, earnings derived from this market totaled more than €1 billion. Suction-assisted lipectomy (liposuction) is the most frequent cosmetic procedure in the United States and Germany. Approximately 200,000 procedures were performed in Germany in 2003. Liposuction is lucrative and, because of the lack of restrictive legal guidelines, the procedure is increasingly performed by nonplastic surgeons and nonphysicians, some of whom have little more experience than a weekend seminar. Thus, liposuction is often performed as an outpatient service in an office setting. The public perception of liposuction as minor cosmetic surgery fails to consider the possibility of major complications with potentially fatal consequences.

And again I would agree with this statement.

Case reports of disastrous complications in the scientific and public media are most often related to the physician's expertise and experience, technical deficiencies, aseptic standards, tumescent anesthesia with or without intravenous sedation, fluid overload, major liposuction, multiple procedures in one setting, embolism, postoperative monitoring, bilateral visual loss, and others. Desrosiers et al. in 2004 reported a case of liposuction performed by an unqualified physician in a kitchen leading to necrotizing fasciitis.

I would commend them on looking at this topic. It is unfortunate that it isn't a prospective, controlled study, but it's a start and a reminder that all procedures have complications. To find the true rate of complication we have to be more forthcoming in reporting them.

As fatalities and major complications from liposuctions in Germany have been reported only as case reports and because of the lack of scientific data, we conducted the first nationwide survey of such incidents.

Two thousand two hundred seventy-five questionnaires were returned (65 percent), which contained 72 severe complications, including 23 fatalities following cosmetic liposuction. Sixty-nine of the 72 cases occurred in Germany, two cases occurred in Austria, and one case occurred in Switzerland. All 72 procedures took place within a 5-year period from 1998 to 2002.

Here is a list of the Collected Complications:

Bacterial Infection--There were 29 cases of bacterial infection (out of 2275 procedures--I will repeated note this number to try to keep things in perspective).

  • Necrotizing fasciitis -- the most frequent with 14 of the 29 cases. Despite the fact that nine of these 14 patients had the liposuction performed in an office setting, there was no evidence of any conspicuous deviation of hygienic standards.
  • Sepsis -- Thirteen patients (out of 2275 cases) experienced various types of sepsis. Five of these 13 patients died.
  1. Streptococci -- six of these 13 cases
  2. Toxic Shock Syndrome -- caused by infection with Staphylococcus aureus was reported in five cases.
  • Gas Gangrene -- Two cases of gas gangrene were found (out of 2275 procedures)

Skin Necrosis (Abdominal Wall) -- There were 10 cases (out of 2275 procedures) of skin necrosis reported. All were located at the abdominal wall region and occurred as a result of a very superficial suction technique.

Perforation of Abdominal Viscera--occurred in nine cases (out of 2275 procedures. Three patients died after developing peritonitis.

Data from a large study showed that one of seven liposuction fatalities was attributable to perforation injuries, which makes intraperitoneal trauma a major risk factor for this procedure. (reference to the 3rd article listed below)

  • Perforation of Small Intestine-- 7 of the 9 cases
  • Perforation of Gallbladder -- 1 of the 9 cases
  • Perforation of Superior Epigastric Artery -- 1 of the 9 cases

Embolism -- All of these cases (8 out of 2275 procedures)demonstrated significantly high suction volumes between 4 and 6 liters in combination with operation times of more than 4 hours. General anesthesia was used in all cases with ensuing embolism. There was no individual or family history indicating a thromboembolic disposition or any evidence of a preexisting bleeding disorder. Two patients in this group died.

  • Pulmonary Embolism-- was evident in seven cases. A deep vein thrombosis was detectable in five cases following liposuction of the lower extremities.

Pulmonary embolism accounts for approximately one of every four liposuction-associated fatalities in different reports. Almost every embolism reported after liposuction occurred after an extensive procedure performed under general anesthesia. The operation time in all six cases with embolism in this study was more than 4 hours.

  • Arterial Embolism --One case of arterial embolism was followed by gangrene of the forefoot.

Hemorrhages -- There were seven (out of 2275 procedures).

A combination of high-volume liposuction (2.5 to 24 liters) with prolonged total operation time (3 to 8 hours) was found in all seven cases with significant hemorrhages. Excessive bleeding was found in four cases. In one case, the surgeon used a combination of tumescent and general anesthesia to perform an 8.5-hour procedure producing a suction volume of 24 liters. Still, the patient survived a disseminated intravascular coagulation, a prolonged intensive care unit stay, and the formation of a massive seroma.

Cardiac Arrest -- Six patients (out of 2275 procedures) sustained a cardiac arrest.

However, because of the incomplete documentation, the exact circumstances remain elusive. Tumescent anesthesia and intravenous sedation was used in four of these six cases. Two patients died secondary to intraoperative cardiac arrest under general anesthesia. Again, the circumstances and causes of this particular case remain obscure. Lidocaine was not used in excessive dosages in any of these six cases.

Fluid Imbalance Issues

  • Hyperhydration (Pulmonary Edema) -- 2 cases (out of 2275 procedures)

Patients with obvious cardiovascular disease are classified as American Society of Anesthesiologists class III or IV, which represents an absolute contraindication for cosmetic liposuction. Nevertheless, in this survey, we found two liposuction patients with documented American Society of Anesthesiologists class III who suffered pulmonary edema following intravenous infusion of more than 3 liters, which required intensive care unit therapy.

  • Hypohydration (Shock, Epilepsy) -- 3 cases (out of 2275 procedures)

In turn, three patients experienced severe consequences from inadequate intraoperative hydration and developed shock, epilepsy, and a stroke, respectively.


1. Liposuction is a surgical procedure and must be performed under aseptic conditions.

Liposuction can create a wound area of up to 1 m2 between skin and muscle fascia that can act as an ideal growth medium for bacteria. Liposuction is not a harmless procedure but a surgical intervention necessitating aseptic standards as in any other elective surgical procedure. Almost all cases of necrotizing fasciitis in this survey had become clinically evident within the first 24 hours after surgery, which should serve as a reminder to reexamine all liposuction patients within this time period.

2. A preoperative medical history and a physical examination of the patient needs to be done before surgery. We surgeons need to make sure the patient is healthy "enough" to have the proposed surgery.

3. Give consideration to seeing liposuction patients for follow-up within 24 hours after discharge to look for early signs of problems. I think this is extremely important if superficial liposuction (for extreme sculpting) is done or large area/volume is done. Remember that:

Liposuction can create a wound area of up to 1 m2 between skin and muscle fascia that can act as an ideal growth medium for bacteria. Liposuction is not a harmless procedure but a surgical intervention necessitating aseptic standards as in any other elective surgical procedure. Almost all cases of necrotizing fasciitis in this survey had become clinically evident within the first 24 hours after surgery, which should serve as a reminder to reexamine all liposuction patients within this time period.

4. Proper training for liposuction, as with any surgical procedure, includes being able to recognize complications and treating them when they occur. Most of the complications listed above (and in other articles) occur when one or more of the following occur

  • High volume liposuction is done (more than 4 Liters removed)
  • Poor technique is used (no excuse in my book for ever perforating an intra-abdominal structure).

The development of skin necrosis following liposuction is almost always a consequence of poor surgical technique. In particular, a very superficial suction technique will regularly result in the destruction of the subcutaneous vascular system.

  • Combination of surgeries done at one time--The surgeon should add up the estimated blood loss and time of each procedure. It is often just safer to do things in stages. Better to "inconvenience" the patient than to have one die.
  • Saying yes to a patient who is not a candidate (see above under the pulmonary edema section). It is the surgeon's duty to say no when the procedure is elective and the patient is not a candidate (for whatever reason--not healthy enough, wrong expectations, etc).


1. Major and Lethal Complications of Liposuction: A Review of 72 Cases in Germany between 1998 and 2002; Journal of Plastic and Reconstructive Surgery, 121. 396e. 2008; Marcus Lehnhardt, M.D.; Heinz H. Homann, M.D.; Adrien Daigeler, M.D.; Joerg Hauser, M.D.; Patricia Palka, M.D.; Hans U. Steinau, M.D.

2. Don't Try This at Home: Liposuction in the Kitchen by an Unqualified Practitioner Leads to Disastrous Complications. Plast. Reconstr. Surg. 113: 460, 2004; Desrosiers, A. E., III, Grant, R. T., and Breitbart, A. S.

3. Fatal Outcomes from Liposuction: Census Survey of Cosmetic Surgeons; Plast. Reconstr. Surg. 105: 436, 2000; Grazer, F. M., and de Jong, R. H.

4. Physician Profile: Dr. Jeffrey Klein; Pioneer explores tumescent local anesthesia with subcutaneous; Vein Therapy News, Vol 1, No 4, June/July 2008 (a interesting look at Tumescent infiltration)