Sunday, November 30, 2008

SurgeXperiences 212 – Call for Submissions

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active and it was easier than checking each one. 

The next edition (212) of SurgeXperiences will be hosted by QuietusLeo at the Sandman, on December 7th.  He is an Israel-based anesthesiologist.  He recently celebrated his 1st year blog anniversary.  You can read his own  call for submissions here.  I love his description of himself.
"An anesthesiologist in Israel. I put ‘em to sleep with my sparkling personality and rapier wit.”
The deadline for submissions is midnight on Friday, December 5th.  Be sure to submit your post via this form.
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.
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, November 28, 2008

Work in Progress

I did my general surgery residency in Wheeling, WV. When this fabric was “issued” more than 10 years ago, I knew I “had to have it”. There were 33 different fabrics in the collection called “Victorian Wheeling” which was designed by Jennifer Simpson. I bought a set that included a fat quarter of each fabric. I put it away. Recently I decided I really needed to decide what to do with it.

After a false start, I settled on the spool block. It seems right to me. It combines my sewing (the spool of thread) and does a nice job of showing off the fabrics.
Each spool block is six inches square. I machine pieced each block, but when I sewed the blocks together by machine I didn’t like the way the “points” came together. I took them apart and sewed the blocks together by hand. The quilt is going to be a wall hanger. I’m going to add a black border with more spools in the corners. I think I may hand quilt this one, but am not sure yet.

Wednesday, November 26, 2008

Engage with Grace

 Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active and it was easier than checking each one.

We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it.
This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences. But our end of life experiences are about a lot more than statistics. They’re about all of us. So the first thing we need to do is start talking.

Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we’re asking people to share this One Slide – wherever and whenever they can…at a presentation, at dinner, at their book club. Just One Slide, just five questions.
Lets start a global discussion that, until now, most of us haven’t had (photo credit).

Here is what we are asking you: Download The One Slide and share it at any opportunity – with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.
Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them.
Just One Slide, just one goal. Think of the enormous difference we can make together.

(To learn more please go to This post was written by Alexandra Drane and the Engage With Grace team)

Tuesday, November 25, 2008

Shout Outs

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

Sam Solomon, Canadian Medicine,  is this week's host of Grand Rounds.   You can read it here.

Welcome to Grand Rounds, the weekly anthology of the best of the health blogs. (For those of you unfamiliar with Grand Rounds, which is hosted by a different health blog every week, you can read more about it here.)

The 211 edition of SurgeXperiences is hosted by “M”, the scalpel is mightier than the sword.  The edition is late, but a good one.  I hope you will check it out.

Our friend, Moof, is back blogging and writing about dialysis and other things.  Give her a visit.

I enjoy all of  Dr Theresa Chan’s (Rural Doctoring), but was especially touched by a recent one, “Case:  Forrest vs Trees” (photo credit).
What this case illustrates is the downside of highly specialized care.  Any healthy child gets serial screening eye exams from birth until they register to vote…………  but at least a primary care doctor shines a light into the pupil specifically in search of an abnormal flash of white.  I suspect this part of her exam had not been done for years, or done only perfunctorily, by the specialists who were so involved in her kidney disease.  Please understand, I'm not blaming them for missing this diagnosis.  I just wish she'd had regular contact with a primary care pediatrician who might be rusty on anti-rejection protocols for transplant patients but who would have reached for the ophthalmoscope out of years of habit and care.

Kathleen, A Respository for Bottled Monsters, has made more discoveries (photo credit).  The photo is the third one in the post.  I hope she finds the final picture and shares it.
I found this series when doing research for someone the other day.  The initial photo of Albert Bauer, a soldier wounded in World War 1. 
The first medical illustration demonstrating the surgical procedure used to correct it.
And the continuation of the procedure:

I haven't come across the final picture but hope I do. I'd really like to see the finished reconstruction.

Enrico, Mexico Medstudent, discusses how HIIPA is sometimes hostile (or maybe just the people who interpret it are).
In my case, I called wanting a report from a minor surgery a few weeks after I had it done. I had already called the surgeon’s office and they said that while they did have a copy via their electronic medical record (EMR), the actual operative report was the hospital’s property and they couldn’t give me a copy; they just had viewing privileges, I was told…..
Obviously it didn’t, but the fun was just about to begin….

There will be no  Dr Anonymous' Blog Talk Radio show this week.  When the show returns on December 4, Enrico will be the guest host.   I hope you will check it out.

SurgeXperiences 211 is up!

The 211 edition of SurgeXperiences is hosted by “M”, the scalpel is mightier than the sword. She has this to say:

Apologies about the lateness of this issue but fear not, my tardiness in no way reflects the quality of this round's submissions. This round's theme is one that is rather close to my heart. Surgery, for whatever reasons, is a defining act. Regardless of our respective roles in the operating room--whether it be as patient, surgeon or orderly-- it forces us to acknowledge our own mortality, our limitations and our boundaries. Though an old cliche, it is the struggle that gives shape.

The next edition (212) will be hosted by Quietus, the Sandman, on December 7th. The deadline for submissions is midnight on Friday, December 5th. Be sure to submit your post via this form.

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.

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.

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Monday, November 24, 2008

Bikini Lip Reduction

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

Just now getting to writing up this article.  I think it is a really nice approach to oversized lips and a good procedure to add to one’s skills.  The article is The “Bikini” Lip Reduction: An Approach to
Oversized Lips by Drs Fanous, Brousseau, and Yoskovitch.  The full reference is given below.  It is a simple, but elegant description of a technique for lip reduction.
………. The reduction of very large lips is not a new procedure but remains a relatively unused one and has received little attention in the literature.  The following presents a modified method for lip reduction referred to as the “bikini” reduction, consisting of excising a “bikini top” (two cups and a middle strap) from the upper lip, and a  “bikini bottom” (a triangle) from the lower lip. This  technique is unique in that it focuses not only on lip reduction but also on labial contouring and volume balance. ……………..
The patient is asked to close the lips gently. A marker
is used to place a dot in the midline between both upper and lower lips at the actual dry/wet junction (Fig. 1, center, points a and a=). The patient is then asked to open the lips slightly, as the surgeon manipulates the
lips with his or her fingers by rotating them inward,
attempting to make them appear smaller.  The patient
then closes the lips. This is repeated until the size of the
showing vermilion is adequately reduced, ensuring the lower lip remains roughly 40 to 50 percent more voluminous than the upper one.
Then, another dot is made in the midline on the newly created dry/wet interface (Fig. 1, center, points b and b=). The patient then opens the lips, revealing four central dots (a, a=, b, and b=).
The bikini design is now implemented (Fig. 1, center).
The bikini top is marked by drawing the central strap
as two parallel lines between a and b for a distance of
approximately 1 cm, then diverging to form two oval
cups bilaterally. The cups’ anteroposterior dimension
(c to d) should be approximately double that of a to b
and should end in a tapered manner a few millimeters
before the commissures. The bikini bottom is drawn as
a triangle (e to b= to f), with points e and f stopping a few millimeters from the commissures……..
I hope you will look up the article and read the entire work.  For more information on lip reduction, also, check the other references and the post I did on lip reduction back in January.

1.  The “Bikini” Lip Reduction: An Approach to Oversized Lips; Plastic and Reconstructive Surgery:Volume 122(1)July 2008, pp 22e-23e; Nabil Fanous, M.D., Vale´rie J. Brousseau, B.Sc.H., M.D.C.M., Adi Yoskovitch, M.D.
2.  Reduction cheiloplasty for upper lip hemangiomas; Plast. Reconstr. Surg. 88: 222, 1991.; Hauben, D. J.
3.   A simple surgical remedy for iatrogenic excessively thick lips. Plast. Reconstr. Surg. 110: 1329, 2002; Botti, G., Botti, C. H., and Cella, A.
4.  Reduction cheiloplasty: An adjunctive procedure in the black rhinoplasty patient. Arch. Otolaryngol. Head Neck Surg. 114: 779, 1988; Stucker, F. J.
5.  Correction of thin lips: “Lip lift.” Plast. Reconstr. Surg. 74: 33, 1984; Fanous, N.

Sunday, November 23, 2008

Thank You!

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

Thanks to Dr Rob (Musings of a Distractible Mind) who has just given me the Kreativ Blogger Award!  Each winner of the award gets to list six things he or she is happy about.  With Thanksgiving upon us, it seems like a perfect time to do this list.
1.  I’m thankful for my family.   Yes, we sometimes disagree but that’s okay.  My dear husband still loves me, even after 18 years of marriage.
2.  I’m thankful for my friends, both real life and all of you (via the web).
3.  I’m thankful for my health.  Despite a few aches and pains (now that I’m over 50 yr) my hands still work and I can still walk/ jog / dance (okay not well, but with joy).
4.  I’m thankful for my neighbors.  One lets me use her walking trail with pond for my dog.  We look out for each other.  I know I could call them if I needed to do so.
5.  I’m thankful for the leaves I need to rake.  It means that I have trees to shade my yard in the summer.  And today, thankful for the rain that allowed me to put off raking those leaves.

So who should I tag for this MEME?   I went back to Dr Rob’s and to Bronnie (HealthSkills Blog) to be sure I didn’t duplicate them.   I thought I would go international.
TBTAM – a New York Beauty.  I wish I could cook like she does.
Dr Cris – another female surgeon who sews and knits in Australia
Silvia – the Italian quilter who sent me the lovely little quilt
Sterile Eye –a talented videophotographer in Norway

Dr Rob’s are the first four (his fifth was me) and Bronnie’s the last six.

  • Vijay - The nicest radiologist in southern India I know.
  • Theresa - at Ruraldoctoring - Remains nice despite her job turmoil
  • Liz - who blames me for her Mac purchace.  Even though I am hurt, I pick her.
  • Fizzlemed - a premed fixing to take the plunge.  Aghast at nasal suction devices.
  • Borealnz beautiful blog - stunning photographs and commentary from New Zealand
  • cb’s Fighting Monsters blog - a social worker in Britain with a wonderful wit and insightful thoughts
  • Salford University Occupational Therapy Education blog - learn more!
  • Musings of a Distractible Mind - Dr Rob’s humour is almost as nutty as mine! I have no llama.
  • Shrinkrap - a trio of psychiatrists, as they say ‘a place to talk where no-one has to listen’
  • HumanAntiGravitySuit - heady intellectual stuff from a Professional Human Primate Social Groomer and Contented “Neuroplastician” (a.k.a. Physiotherapist) 
  • It's Arrived!

    Did you remember that I took part in ALQS (Another Little Quilt Swap)? I received my little quilt yesterday! I think it is beautiful! It came to me from Silvia who lives in Italy!!!

    The quilt I made for the swap can be seen here.

    Friday, November 21, 2008

    Cracker Baby Quilt

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

    This past Monday (Nov 17) I mailed this quilt to fellow blogger, Fat Doctor, for the new baby she and her husband are adopting. the baby is due soon. She beat me to posting about the quilt (smile).

    I first saw this quilt block pattern, cracker block, over at Kate’s Quilting Blog. She had noted that instructions for it were available here. I bookmarked it. It is a nice block for using fabric that you only have in small amounts (partial or full fat quarters). Each block is 6 in square. This small baby quilt is 42 in X 42 in. I machine pieced and quilted it.
    Here is two detail photos. I used a golden yellow thread for the quilting. There are hearts in the center muslin squares and around the border.

    Thursday, November 20, 2008

    The Ethical Challenge and Surgical Innovation

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

    The short articles referenced below make for thoughtful, interesting reading. I had a similar discussion once during an ethics CME course I took. Most there thought that any “change” in an operation was risky and maybe unethical as the surgeon was “not trained” for it. My view point as I tried to explain it, was that like dress-making or tailoring, surgery is based on good skills. If I know how to put in a zipper or do a collar or do button-holes well, then you can put all those together to do more than just make a dress. I should be able to put those skills together to make a suit coat. That simple example opened (didn’t necessarily change) up the minds of most there.
    That example is way too simple and there do need to be ways to make sure that surgeons who left their residency PRIOR to learning a technique that came along ten years later (laproscopy is a great example) have properly learned the technique prior to being given hospital privileges. What is the learning curve? Who should oversee them while they do their first six or ten or twenty cases? What if they are the first in the community to learn the skill (went to the university and took a week long course)?
    Here are some short bits to entice you. This is from Dr Clayman.
    The challenge for the surgeon as a creative being is that unlike all other arts, the surgical medium is sensate. Every alteration in a tried-and-true technique
    exposes both the surgeon and patient to censure and unknown complication, respectively…….
    The question arises, at what point along the creative continuum does a minor variation on a theme become an innovation? When does the surgeon-scientist need to ask or request a panel of peers to review an idea or concept and judge it—seeking permission prior to performance? How well equipped is the average institutional review board (IRB) panel, all too often composed of a minority of surgeons, able to pass judgment? ………….
    The surgeon today, through technology, seeks to accomplish a surgical cure while lessening surgical
    morbidity, hence the advent of minimally invasive surgery. However, as the incision wanes, the technology waxes and thus the surgeon must now enter a realm unfamiliar, that of the medical industrial
    complex. While the surgeon is thinking less pain, quicker convalescence, better cosmesis, the industrial
    side of the partnership is evaluating potential profit/loss, marketability and expense of development. In this light, it is essential that the IRB stand between the innovator and the patient, just as the FDA now stands between industry and the patient….
    In this regard the sage advice of Dr. Agich bears repeating: “We need a well-grounded set of criteria to differentiate at least three types of cases: routine or
    normal variation; innovation that is beyond routine, not formal research, yet requires review; and innovation that involves research and so requires formal IRB review.”
    However, as with most gradations, the extremes are obvious (one and three), it is the middle ground (two) that provides the greatest challenge and concern…….
    Both articles are worth reading and discussing.
    Dialogue: The Ethical Challenge Posed by Surgical Innovation by Ralph V Clayman, MD with Response by George J Agich, PhD; Lahey Clinic Journal of Medical Ethics, Fall 2008, Vol 15, Issue 3, pp 6-7 (pdf file)
    The Ethical Challenge Posed by Surgical Innovation by George J Agich, PhD; Lahey Clinic Journal of Medical Ethics, Spring 2008, Vol 15, Issue 2, pp 1-2 (pdf file)

    Wednesday, November 19, 2008

    Medical Method Patents

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

    Do you know anything about medical method patents?  I knew very little (and even now am no expert) when I noticed this very interesting article (first reference below) on the subject and how it is polarizing the phlebology community in the Oct/Nov 2008 issue of the Vein Therapy News. 
    Medical method patents came along with the introduction of the  laser and Diomed’s endovenous laser ablation (EVL) procedure and the VNUS Medical Technologies Inc. Radio Frequency generator and it Closure system.
    ………………..The vein treatment industry in the United States has become an indecipherable web of legal entanglements over medical method patents, trade secret issues and other patent litigation that is complicated by pending cases and bankruptcies.  This has been further complicated by the speed –or rather lack thereof—of the court system in the United States in resolving the issue in a highly competitive marketplace with a high degree of conflict………..
    The United States and Australia stand alone in defiance of 80 other countries in the world by allowing medical method patents.  Of the 100 or so medical method patents issued a month in the United States, about half are issued to foreign doctors who come here to register their patent because method patents are not allowed in their own country.

    The second article listed below by David Gornish, Esq gives a nice summary of patents and definitions.  So what is a medical method patent?
    Another area of particular interest to physicians is the patentability of medical methods, e.g., surgical procedures or methods of treatment (including new uses of existing drugs). In the United States, medical methods are patentable subject matter. The apparent catch-22 is that medical method patents cannot be enforced against doctors or hospitals. Naturally, the question arises as to what value a medical method patent has if it cannot be used to stop the very people likely to infringe.
    The quick answer is that, while direct infringers (i.e., doctors) are shielded from liability for infringing medical method patents, indirect infringers (e.g., companies) are not. For example, where medical device companies or pharmaceutical companies design or promote their products specifically to be used in patented procedures or methods of treatment, the companies could be considered indirect infringers. Such companies may be inclined to purchase a license from the patent owner.

    Back to the first article, and I would say this would apply to any area of medicine where method patent law/lawsuits are an issue.
    When President bill Clinton signed the bill into law in 1996, physicians were granted limited immunity protecting them from suits alleging patent infringements.
    While it might seem that this law would have pulled all the teeth from the arguments and issues being decided in court at great expense, it in fact moved the liability for infringement from the backs of infringing doctors and onto the backs of the companies from whom those doctors purchase the devices and procedure kits for the minimally invasive system used to treat varicose veins through the legal concepts of contributing to and inducing doctors to infringe the patents.
    Just as water flows downhill, the real costs for royalties and litigation now moves from the company that has lost or settled a lawsuit to the doctor who buys products from that company. ……as more competition disappears, then prices will continue to rise.   Unlike a retailer who can always pass along the cost of overhead to customers in the form of higher prices, doctors cannot do that because medical reimbursement limits are locked in, and one doctor predicted this was going to end badly for phlebology as a whole……….
    Although he said he has not yet personally encountered any problems, _________, is typical of may physicians in evaluating the effect of the medical method patents on his practice.  “Reimbursement is at rock bottom levels now, and I simply could not afford to shoulder additional un-reimbursed expenses,” he said of increased costs for supplies and royalties.  “Thus, my patients might be stuck with now outdated treatment, or be forced to seek the more current treatment from institutions with deeper pockets.”

    I have never “invented” or radically “improved” a medical procedure and perhaps that is why I tend to think we should be a medical community sharing and teaching ideas/treatments.  I happen to agree with Dr. Goldman (3rd reference below)
    “I am totally opposed to medical method patents.  It is a waste of time and money.  When we take our oath to be doctors, part of that oath is to teach and to advance patient care.  I think that some people have forgotten their oath and it’s appalling.  And it’s not even mostly the doctors.  There are a few doctors who have forgotten their oath, but mostly it is these business people.  They take advantage of well meaning physicians.?

    Medical Method Patent Litigation Polarizes the Phlebology Community; Vein Therapy News, Vol 1, No 6, Oct/Nov 2008; by Larry Storer (online site is behind, but should eventually be available here)
    Patent Laws for Physician Inventors by David Gornish, Esq; Physician's News Digest, May 2008
    VNUS Patent Inventor, Mitch Goldman, Opposes Method Patent; Vein Therapy News, Vol 1, No 6, Oct/Nov 2008; by Larry Storer (online site is behind, but should eventually be available here)
    VNUS Responds to Method Patent Litigation Article (Official response from VNUS Medical Technologies Inc.); Vein Therapy News, Vol 1, No 6, Oct/Nov 2008 (online site is behind, but should eventually be available here)
    Patents on Medical Procedures and The Physician Profiteer by Susan leach DeBlasio; FindLaw for Legal Professionals (2004)
    Should Patenting of Surgical Procedures and Other Medical Techniques by Physicians be Banned?  by Silvy A Miller; PTC Research Foundation of Franklin Pierce Law; IDEA: The Journal of Law and Technology, 1996 (pdf file)

    Tuesday, November 18, 2008

    Shout Outs

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

    Dr Deb  is this week's host of Grand Rounds.   The “iPod” edition! You can read it here (photo credit).

    Welcome to Grand Rounds 5.9 - a weekly rotation of blogposts in the medical and health fields. I am delighted to be your host again, and present to you the following for your listening pleasure.

    Emily, CrzeGrl, Flight Nurse, is the host of the current issue of Change of Shift (Vol 3, No 10).   You can find the schedule and the COS archives at Emergiblog.  Go check it out (photo credit)
    Welcome to Change of Shift Vol. 3, No. 10. I have the honor and privilege to be co-hosting this edition with his excellence Zippy the Lobster!
    For those of you unaware of Zippy’s adventures in his quest to raise money for Children’s Brain Cancer research, check him out at

    Dr Judy Paley, Denver Doc,  needs your help:
    I am collaborating with my friend and colleague Gail Harrison (who has been there/done that cancer journey) on a book for newly diagnosed cancer patients. Please consider sharing your stories if you have been down that road as well, or pass this questionnaire on to a friend or family member who has been through this experience.

    Via Medical Industry News Impact comes a link to this article, Retiring physician Bill Lippy passing on his knowledge via an online library by Mary Vanac.  Very nice!
    He, his partner Dr. Leonard Berenholz, and his son, David, have created a video library about stapedectomy and otosclerosis for doctors everywhere. The Lippy Library is available online at

    Felice Aull, Ph.D., M.A. (Literature, Arts, and Medicine Blog) has posted a syllabus for her humanities course online.  It is amazing.  I plan to sample it and maybe work my way through the entire thing.  I hope you will check it out.
    Now that I’m semi-retired, an elective course that I developed and taught for fourth-year medical students is retiring with me. I’m writing about it here, in the hope that other medical humanities educators might wish to adapt it for their teaching — it was very well received by participating students and, I think, served a useful function. (I believe Linda Raphael has introduced a version at George Washington University School of Medicine). I taught “Betwixt and Between: Borderlands and Medicine,” for seven consecutive years at NYU School of Medicine, modifying it somewhat each year. The idea of adapting a borderlands theme to an examination of the medical profession came to me while studying the work of Edward Said and Gloria Anzaldua as I was working toward a master’s degree in humanities and social thought (35 years after getting a Ph.D. in medical science). Below I summarize my motivation for developing the four-week course and elaborate on the syllabus. References annotated in the Literature, Arts, and Medicine Database are linked. Full reading references are listed alphabetically.

    Steven Novella, Science-Based Medicine, discusses the "debate about off-label prescriptions".  Really worth the time it takes to read the entire post.
    So-called off-label uses of prescription drugs is an enduring controversy - probably because it involves a trade-off of competing value judgments.The FDA is considering loosening its monitoring of off-label prescriptions, but critics are charging that, if anything, regulations should be tightened. Many issues of science-based medicine are at the core of this controversy………
    The core dilemma stems from the conflict between freedom and regulation for quality control. We want to protect the public from the misuse of medications, but at the same time allow physicians to use the best available scientific evidence to make individual medical decisions with their patients…….

    Via Dr Wes, who feels that Ben Brewer, MD  is talking sense as he “lays out his proposal to treat our health care crisis”.  I agree with him.  Read Dr Brewer’s article.  Here is part of what Dr Wes says at the end of his post (talking sense):
    So I can hear it now: "What will happen to all of those people paid to collect the data? They might become unemployed at this time of our colossal economic downturn! Our unemployment numbers will go up! We can't have that!"
    We cannot afford NOT to make a significant change to the way we do health care today. I am convinced as Americans consider the options ahead of them, that they'll make the right choice and realize the consequences if they don't. Dr. Brewer's proposal makes a lot of sense.

    Michael Carroll will be the guest on the Dr Anonymous' Blog Talk Radio show this week.  I hope you will check it out.
    I also hope you will join us this Thursday night at 8 pm CST (or 1 am GMT) both to listen to the show and to participate in the chat room. That's where all the fun is.

    Monday, November 17, 2008

    The Effects of Breastfeeding on Breast Esthetics

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

    This is an article review – The Effect of Breastfeeding on Breast Aesthetics by Brian Rinker, MD, Melissa Veneracion, MD, and Catherine Walsh, MD (full reference information below). The full article can be read here (pdf).
    It is widely know and accepted that breast milk is good for infants (ie lower risk of many acute and chronic illnesses, transfer of maternal antibodies, etc). Despite this many woman are reluctant to breast feed because of the fear that it will adversely affect the appearance of their breasts.
    However, rates of breastfeeding remain low in many industrialized and developing countries. In a 2003 survey, 66% of new mothers reported an intent to breastfeed, and the rate of breastfeeding at 6 months after delivery was 32.8%.6 Despite widespread advocacy, these rates have not changed substantially in more than 20 years. One of the most common reasons cited by women for electing not to breastfeed is the fear that lactation will adversely affect the appearance of the breasts.
    Pediatricians and lactation experts have tried to dispute this notion, but it continues to be held by many women.
    but is widely held by women and seems to cross both cultural and socioeconomic boundaries
    This article is an attempt to look at the issue in an objective manner. They did this by a retrospective study of charts.
    Methods: Charts were reviewed of all patients seeking consultation for aesthetic breast surgery between 1998 and 2006. History of pregnancies, breastfeeding, and weight gain were obtained via telephone interview. Degree of breast ptosis was determined from preoperative photos. Nulliparous women were excluded. Logistic regression analysis was performed to identify independent predictors of postpregnancy breast ptosis.
    That is the main weakness of the article, but they realize that limitation.
    This is a retrospective study with inherent limitations.
    The patients were not randomized to breastfeeding and nonbreastfeeding groups, and some differences were observed in the composition of the 2 groups.
    A well designed prospective study is needed to further
    elucidate the effects of pregnancy, breastfeeding, and
    smoking on breast shape. Such a study would follow
    healthy women before, during, and after pregnancy, documenting the effects on breast shape and size. The study should follow patients through at least 3 pregnancies, and those in the breastfeeding group would need to have engaged in breastfeeding for at least 3 months. We have begun enrollment for just such a study at our institution.
    Even with those limitations, I think their conclusions are sound. It will be interesting to see if the prospective study validates them. Here are the conclusions:
    A history of breastfeeding was not found to be associated with a greater degree of breast ptosis in patients presenting for postpregnancy aesthetic breast surgery. Age and cigarette smoking, both of which are associated with a loss of skin elasticity, were found to be positive predictors for breast ptosis, as were larger prepregnancy bra cup size and number of pregnancies. Whereas breast ptosis appears to increase with each additional pregnancy, breastfeeding does not seem to worsen these effects. Expectant mothers should be reassured that breastfeeding does not appear to have an adverse effect upon breast appearance, beyond the effects of pregnancy alone.
    The things that a woman can do to help prevent breast ptosis (sagging) are
    • Don’t smoke.
    • Limit the number of pregnancies.
    • Maintain a healthy weight before, during, and after the pregnancy.
    The things you can’t change are your age or the fact that genetics gave you DD cup breasts rather than A cup breasts.

    The Effect of Breastfeeding on Breast Aesthetics; Aesthetic Surgery Journal, Vol 28, No 5, pp 534-537, 2008; Brian Rinker, MD, Melissa Veneracion, MD, Catherine P Walsh, MD (pdf file)

    Sunday, November 16, 2008

    SurgeXperiences 211 – Call for Submissions

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

    The next edition (211) of SurgeXperiences will be hosted by “M”, the scalpel is mightier than the sword,  on November 23, 2008.  She describes herself this way:
    "M" is an eighteen year old medical student with a lot of opinions, a god complex and aspirations for surgery. She likes to write internet profiles in the third person and has a very domestic relationship with "Mr M", a fellow medical student with an ego the size of Canada. Currently residing and studying in anonymity, this blog is a reservoir of asinine rants from a god-stupid first year student. There is no medicine or medical advice to be had here. Go find a real doctor.
    The deadline for submissions is midnight on Friday, November 21st.  Be sure to submit your post via this form.
    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.
    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, November 14, 2008

    Hawaiian Lobster Quilt is Finished!

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

    As mentioned in previous posts here and here, this quilt was conceived to be a fund raiser for Zippy’s charity.  That charity is  Childhood Brain Tumor Foundation - MD. 
    The Hawaiian Lobster quilt is 41 in X 41 in.  It is machine appliqued and machine quilted.  There is hand embroidery around the appliqued edges.  For more information on the quilt, please, check the previous posts mentioned above.  Here are pictures of the finished quilt.

    This is a photo to show more of the detail.

    Here is a photo of part of the back of the quilt.  It shows the quilting of the flowers and leaves along the border.

    I would also like to announce that the auction for the quilt will begin on Monday December 1 at 6 am CST (no early bids will be excepted), and ask that you help me spread the word. It will be a silent on-line auction.  If you would like to simply donate to the charity rather than make a bid you can do so here.  Here are the rules:
    • I have set up an e-mail account for the sole purpose of this auction.  It is lobsterquilt(AT)gmail(DOT)com
    • If you wish to make a bid, email me at the above address with “auction” in the subject line.  Include your name, the amount of the bid, and a working email address.  I will e-mail you back that the bid was received and give you an identifier number.  This will be how I “track” each bidder and their subsequent bids.
    • The bidding will start at $200.  The minimal increment will be $10 for subsequent bids, though I would love to see the increments increase by $25 or more.
    • Several times a day, during my awake hours and as work permits, I will tweet and post the current bid and time it was received.  The bidder’s name will not be posted, but the bidder’s identifier number will be.
    • So you can check my tweets or check back here to see how the bid is going.  Take note:  I will mainly use twitter for the updates!
    • If you have sent a bid to me that was higher than the one posted, please, be aware of the time received (it will be CST) and either recheck later or e-mail me again.  We all know that sometimes e-mails are lost.
    • The auction will last two weeks.  Bidding starts Monday December 1st  and closes on  Monday December 15th at noon (CST).   I will notify the winner by e-mail shortly thereafter. 
    • The winning bidder will be required to make a donation here at First Giving in the amount of the bid (or higher) and asked to leave a comment “I won the lobster quilt!”  They will then need to forward a copy of their receipt so that I can match the name/e-mail address to the winning bid.  This will need to be done within 48 hrs (or by December 17, 5 pm)
    • Once the donation is confirmed, then arrangements will be made with the winning bidder on shipping.  Shipping costs and any insurance will be the winner bidders responsibility.  Options will be US Postal, Fed Ex, or UPS.

    Thursday, November 13, 2008

    Getting Back Into Shape

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

    I am a strong advocate for physical activity.  Any physical activity.  I encourage my patients, friends, family to find something they like to do and DO IT.   For one sister that means running 5K’s, half-marathons, full marathons.  For my mother, it’s the senior citizen dances.  For my husband, it’s running on the treadmill.  For me, it’s walking (walk/jog) my dog and shooting baskets in the back yard.  (Okay—it also includes dancing to the radio and commercials.)
    If you haven’t been active in a long time and are seriously de-conditioned, start slow.  There is a program called “The Couch-to-5K Running Plan” which offers some good advice and an easy to follow plan. 
    Or you can follow the plan at Shape Up America! 10,000 Step Program which uses a pedometer to keep track of how much (or little) you move each day.
    With Halloween just past (all that candy) and Thanksgiving and Christmas coming up, now is a good time to get moving or keep moving.   Here is the post I wrote last November on using a pedometer

    I use a pedometer as a reality check. I often go home tired after a day in surgery or in the office. I'm tired so I must have expended a lot of energy and therefore used a lot of calories/done a lot of moving right? Wrong! In the course of a "normal" day most adults take anywhere from 900 to 3000 steps in a day and not much more. That means to truly get "enough" physical activity in daily, I (and you) need to go for that daily walk. Fortunately, I enjoy walking. Most days (barring horrible weather) I enjoy my walks with my dog. Other days--I just do it--rain or cold or heat. This is a picture of my pedometer with my step count on a surgery day. It includes the time from getting dressed to just finishing in the operating room. Notice how few steps have been taken.
    JAMA recently had an article (referenced below) that showed "The results suggest that the use of a pedometer is associated with significant increases in physical activity and significant decreases in body mass index and blood pressure." Overall, the pedometer users increased their physical activity by 26.9% over baseline. The person who gets the most out of the use of a pedometer is the who has a step goal (ie 10,000 steps per day).
    The JAMA article also found "Pedometer users also significantly decreased their systolic blood pressure by almost 4 mm Hg from baseline. Reducing systolic blood pressure by 2mmHg is associated with a 10% reduction in stroke mortality and a 7% reduction in mortality from vascular causes in middle-aged populations; thus, it is critical that the effects of pedometer use on blood pressure be examined closely in future studies."
    Perhaps you might think about getting a pedometer for someone for Christmas or even one for yourself. It does not need to be an expensive one. I use the Sportline 340 (having lost a few, they cost less to replace). I never bothered to program in my step length. I simply use it to count the steps and aim for that 10,000 mark. Most days I go past it, but there are days I have to "work" at it. Simple adjustments will add up--park the car farther away from the store, take the stairs down two flights or up one rather than using the elevator, walk one extra block, etc.
    Some suggestions on getting started with your new pedometer...
    • Start out by wearing the pedometer each day for two weeks and don't do anything to change your normal routine. Keep an exercise log of the daily step count. At the end of the second week, take a look at how many steps you are taking each day in the course of living your life.
    • If you feel comfortable doing so, take the highest number of steps you have walked on any given day during that 2 week period. Use that number of steps (ie 2500 steps) as your first daily step goal. To avoid injury, do not select a higher number. Continue to keep your step log.
    • At the end of that two week period, review all the steps you took each day. If you are ready, add another 500 steps to your daily goal. Your new step goal is now 3000 steps a day for the next two week period.
    • Continue in that manner, working up until you finally reach the goal of 10,000 steps a day.
    • The goal is to keep you active for the rest of your life. So don't go overboard and injury yourself. Take it slow. Take it easy.
    • It takes about six months to "lock in" a new behavior. Aim to do what is necessary to change your exercise behavior permanently. Be prepared to dedicate yourself to your daily goal each day for a minimum of six months. If you do that, you are much more likely to maintain this goal permanently.
    • If you skip a few days due to illness, work or other obligations, the sooner you get back into the exercise groove, the more likely you will be able to get back into your routine.
    • Reaching that walking activity goal of 10,000 steps does not mean that you can increase your food intake. Continue to try to eat a healthy and reasonable portion diet.
    • So the weather's yucky, walk laps at the mall, go to a museum, or walk laps inside your home. Get up and move!
    Here's my total at the end of the day.
    Using Pedometers to Increase Physical Activity and Improve Health: A Systematic Review; Dena M Bravata, MD and others; JAMA, Nov 21, 2007, Vol 298, No 19, pp2296-2304
    Shape Up America! 10,000 Step Program

    Wednesday, November 12, 2008

    Patient Question – Options for Payment/Coverage of Surgery

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

    The same person who asked the questions here, had more questions regarding how to pay for (self/insurance) procedures that remove the excess skin after weight loss.

    Insurance Coverage
    If you are “lucky” then you have insurance coverage, but as I wrote about here that is not likely.  For most (hesitate to say all, as I have not read all policy booklets), define cosmetic surgery this way:
    Cosmetic Procedures -- services are considered Cosmetic Procedures when they improve appearance without making an organ or body part work better. The fact that a person may suffer psychological consequences from the impairment does not classify surgery and other procedures done to relieve such consequences as a reconstructive procedure."
    So without a medical reason (ie major skin issues, repeated infections, such a large pannus that it interferes with mobility, etc) then the surgery to remove skin from the abdomen, arms, breasts, etc will always be defined as cosmetic.   If you have any of those medical issues, be sure you have them documented by your family physician or surgeon who did your lap band or gastric bypass.  It’s not enough for you to simply say, you have had the skin issues and dealt with them yourself for five years.  That won’t help me help you get coverage.  I can not say it enough, make sure it is documented.

    Indigent Care Coverage
    Most states have a program similar to Colorado’s (pdf file)
    The state does not have sufficient resources to pay for all medical expenses for persons who are indigent.
    The state must allocate available resources in order to increase access to primary care among Colorado’s indigent population.
    So once again, you will need to prove that it is a medically necessary issue that the surgery will improve or correct.  If it is, there will need to be documentation.

    Medical Schools / Residency Programs
    There are no programs that I know of or could find with a google search that allows it’s plastic surgery residents (USA) to perform reduced fee or free surgery just for the training.  If anyone knows differently, please, let me know.

    Physicians and hospitals take most credit cards these days.
    Then there are many companies out there that will gladly loan you money with different interest rates and 1-5 yr pay back plans.   A few of them include:
    Capital One Healthcare Finance
    Care Credit
    Med Loan Finance
    Reliance Finance Company
    Surgery Refinancing

    Medical Tourism
    Not one I really want to advocate, but it is an option.  It is well known that the cost of surgical procedures in other countries is much less than in the United States.  However, please, be very careful if you take this route.

    When you have multiple procedures you need or want to have done, it will often be necessary to stage them for your own health safety (for reasons such as length of surgery, estimated blood loss, etc).  So if you can only pay for one procedure, which would it be.  That in my humble procedure is often the place to start.  It is not always the same place we (patient and I) would start, if there are no issues with money (none of my patients fall in this category). 

    Tuesday, November 11, 2008

    Shout Outs

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

    First, it’s Veteran’s Day here in the United States, so if you haven’t seen this story of how GruntDoc’s blog helped out (via one of his readers)  veteran SSGT Robert Toland, then you need to check this post out.
    Watch the video here, and enjoy the sight of regular people pitching in to help other people.  Beautiful.
    Backstory here and here.

    I caught this story on NPR this morning as I drove in to work.  It is  'American Widow Project' Born From Grief” by Glorida Hillard.  I hope you will check it out.  These young women (and their families) need to be remembered today too.
    Taryn Davis was just 21 years old when her husband was killed in Iraq. As an young widow, she felt bereft, and very alone. She channeled her grief into the "American Widow Project."

    Dr Rob, Musings of a Distractible Mind,  is this week's host of Grand Rounds.   The “job advice” edition! You can read it here (photo credit).

    Interestingly, on Wednesday I got the following email:
    Dear Dr. Rob:
    I have been gunning for this job for over four years and just landed it this week.  I am real excited about it, but need some advice on how to do it best.
    What advice can you give me?
    Anonymous (my name rhymes with “no llama”)!

    November is Pet Cancer Awareness Month.  The Days of Johann, an agility dog! has a nice post on it.  I know many of us have lost dogs to cancer.  You can read about my losses here, here (Ladybug is the one in the picture), and here.   Recently, Shadowfax lost his dog to canine cancer.  Orac's dog Echo died back in July of canine cancer.

    And if you’ve ever wondered how a C-section is done, then check out this simulated one (via Kevin, MD).  Have to agree – cool.
    Cool. (via The Well-Timed Period)

    A thoughtful post from T, Notes of an anesthesioboist, on the recent Boston Globe article regarding drug use in anesthesiologists -- Fallen.  Very sad topic.
    The Boston Globe article paints the picture all-too-clearly: "He was dead when they found him in the storage closet at the hospital...There was a half-filled vial of propofol...a syringe filled with midazolam...empty vials of morphine, hydromorphone, and Demerol...And then there was one nearly empty vial of vecuronium - an intravenous muscle relaxant that...would shut down the body's respiratory system in roughly three minutes, leading to certain death."
    It's that last sentence that I found so chilling………. How horrifying and sad and awful.

    Sterile Eye will be the guest on the Dr Anonymous' Blog Talk Radio show this week.  He is a Norwegian medical photographer.  He often shares his work on his blog.  I hope you will check it out.
    I also hope you will join us this Thursday night at 8 pm CST (or 1 am GMT) both to listen to the show and to participate in the chat room. That's where all the fun is.

    Monday, November 10, 2008

    Tort Reform Revisited

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

    There is an interesting article in the current issue of Arkansas Times (photo credit) on tort reform.  It is written by Doug Smith and titled “Fewer medical malpractice suits, but is that a good thing?”  It discusses Act 649 which was passed in 2003 as Arkansas’ attempt at tort reform.  I recall how insurance companies were fleeing Arkansas in the years prior to this Act being passed.  I have noticed that my malpractice cost has stabilized.
    David Wroten, executive vice president of the Arkansas Medical Society, said there'd been a major change in the medical malpractice market in Arkansas, although, he said “We don't know all the reasons why.” Only a couple of companies were writing medical malpractice insurance before Act 649, he said, and now there are nine. Rates have declined “in some cases,” depending on factors such as the insured physician's specialty, but not across the board. The biggest physician malpractice carrier in Arkansas, by far, is State Volunteer Mutual Insurance Corp., with about 70 percent of the market. “Their premium increases have dropped to nothing, or 3 percent,” Wroten said. “Their claims have been cut nearly in half.” He said the reduction in claims was due in large part to Act 649's requirement that an “affidavit of merit” be filed within 30 days of the filing of a malpractice lawsuit. The affidavit, saying there's reasonable cause for the lawsuit, had to be signed by a physician practicing in the same specialty as the defendant. It was supposed to be a defense against frivolous lawsuits. Lawyers said there were already many such defenses.
    The affidavit requirement was invalidated by the Arkansas Supreme Court last year, the Court saying that the legislative requirement intruded on the Court's own constitutional authority to set the rules for filing lawsuits. Other provisions of Act 649 also are being challenged before the Supreme Court.

    Patient Skin Care Questions

    I recently received any e-mail from a reader

    I found your blog while searching for information on the panniculectomy procedure... thank you for your clear differentiation on this procedure versus a tummy tuck! The pictures gave me the aha moment.   :)

    …... I have not had WLS, but instead have worked at life-style changes. …..So here I am now, roughly 100 pounds down with +/- 70 pounds to go... no insurance coverage and many skin issues to deal with - some cosmetic, but most necessary to prevent the awful skin irritation………. Surgery is cost prohibitive, but lack of surgery leaves us feeling sub-human. There has to be an answer to this - I just must not be Googling it right :p

    I do have a couple of questions if you could take the time to answer them... perhaps you would consider placing them on your blog page……. 


    Here are her questions (rephrased slightly) and then my answers:

    Q1.  Have you come across compression garments that keep the pannus elevated without being miserable to wear?

    • Depending on body type (apple or pear shape for example) this can be difficult to find.  The best advice I can give you is to measure yourself at the waist, across the largest part of the pannus, and beneath the pannus (hips).  You may find (and I realize this may be embarrassing) that the best fitting girdle may be one designed for a pregnant woman.
    • Compare your measurements with the manufacturer’s size chart.  Very often it won’t be clear which size is the one for you.  I would (if possible) try on the one which fits closest to your pannus measurement and also the one which fits the hip measurement.  If the first feels too loose and the later too tight, try the size in-between.
    • Try both panty girdles (medium to heavy grade, as the elastic will last better) and one-piece bra/girdle combinations.  It will be a matter of trial and error, as it is with most clothes.  You will need to try them on.

    Q2.  I have very thin skin - where the stretch marks are from the weight gain and pregnancy.  I always worry about the skin tearing because it is  so thin.

    • This is a very real issue and the skin can tear from the forces exerted on it – ie the weight of the pannus.  Make sure you let your family doctor or dermatologist know when this happens as the documentation of this may help you get your insurance company to pay for the panniculectomy.  This becomes a medical issue not a cosmetic one.  You want it to be documented in your physician’s chart.
    • Prevention of the tearing comes down to reducing the weight or the pull of the pannus on your skin.  If you can find a decent girdle that is comfortable enough to wear, this can help. 
    • Also, babying the skin with non-perfumed, non-alcohol based lotions that won’t irritate or excessively dry the skin will help.  Try using Gold Bond ointment or Aquaphor or A&D ointments.
    • Once the skin tears, it becomes a matter of wound care to prevent infection and allow healing.

    Q3.  I get this horrible red rash or skin irritation under the skin fold and on the corresponding skin it is touching.  It's debilitating, humiliating, and results in an embarrassing odorous discharge.  I have the same issue under the breasts and with my thighs.

    • I have had patients tell me that using deodorant (roll on) in the skin fold to decrease sweating helps. 
    • Wearing clothing that helps prevent the skin to skin contact helps.  For example, the girdle you asked about above.  Finding a well fitting bra that supports the breasts up and away from resting on the chest skin.
    • Good skin care as in the previous question/answer.


    Ultimately there are no simple answers to your questions I’m sorry to say.  I would encourage you to document any skin tearing and/or rashes and/or skin infections you get.  This documentation can help in getting any excess skin excision surgery done in the future classified as reconstructive rather than simply cosmetic.

    Lastly, and maybe most importantly, may I commend you on changing your life style so that you have lost the weight.  I hope you continue to do stick to it.  Thank you for your kind words.


    Other posts that you may find interesting:

    Panniculectomy vs Abdominoplasty

    Insurance and Healthcare Thoughts

    Tips for Finding a Good Bra Fit

    Sunday, November 9, 2008

    SurgeXperiences 210 is up!

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

    The host of SurgeXperiences 210 is From Dupont to Abdoun (photo credit). She has done a wonderful job! I hope you will check it out here.
    This site is a product of my experiences as a Georgetown medical student (near the famous Dupont Circle) on academic sabbatical living in Amman, Jordan (near the not so famous Abdoun Circle). I plan to return to the U.S. in 2009 to complete a residency in emergency medicine. It is my hope to tell the stories of the many wonderful patients and diseases I have encountered, to describe health care in Jordan, and to elaborate (or maybe just ramble) on some of my thoughts about practicing medicine in a developing country. Thanks for reading!
    The next edition (211) will be hosted by “M” at “the scalpel is mightier than the sword” on November 23rd. The deadline for submissions is midnight on Friday, November 21st. Be sure to submit your post via this form.
    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.
    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, November 7, 2008

    Repairing Rusty’s Dog Bed

    My dog Rusty likes to “scratch” or dig at his bed before he lays down. The fabric eventually gave and developed a hole. The egg crate mattress inside is still in good condition.

    I tried to find a replacement cover in the local pet stores, but had no success. So I bought some “lambskin” type fabric and sewed it to the upper part of the cover. This simple fix keep the functioning zipper in place and “resurfaced” the cover.

    Here’s a picture of the happy dog.

    Thursday, November 6, 2008

    Fat Injections for Breast Augmentation

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

    There seems to be a lot of interest in using fat grafts for breast augmentation these days. In the September issue of the Journal of Plastic and Reconstructive Surgery, there are two articles on fat grafting (only one of them to the breast per say). They are the first two reference articles listed below. I thought I would review them for you here.
    The first one: Autologous Fat Grafts Harvested and Refined by the Coleman Technique: A Comparative Study
    Background: The viability of fat grafts obtained by even a well-established technique remains poorly studied and unknown. This study was designed to determine the viability of fat grafts harvested and refined by the Coleman technique.
    Methods: Sixteen adult white women were enrolled in this study. In group 1 (n = 8), fat grafts were harvested and processed with the Coleman technique by a single surgeon from the abdomen of each patient according to his standardized method. In group 2 (n = 8), fat grafts were harvested with the conventional liposuction by another surgeon. After centrifugation, the resulting middle layer of tissue was collected. All fat graft samples were analyzed for the following studies: trypan blue vital staining for viable adipocyte counts, glycerol-3-phophatase dehydrogenase assay, and routine histologic examination.
    Autologous fat grafts have been used successfully for structural fat grafting in facial, lip, and hand rejuvenation and body contour improvement. Many believe that fat, as autologous tissue, can be considered the ideal soft-tissue filler because it is abundant, readily available, inexpensive, host compatible, and can be harvested easily and repeatedly. I agree with that.
    The big If is whether fat grafts can truly survive after transplantation. This has always (and most likely will remain so) been one of the main concerns after fat grafting. The potential for a high rate of absorption over time in the grafted site can be up to 70 percent of the filled volume.
    The most acceptable explanation for absorption has been based on the Peer's cell survival theory, which states that the number of viable adipocytes at the time of transplantation may correlate with ultimate fat graft survival volume.
    So to improve the ultimate long-term result, the technique used to harvest the fatty tissue and to implant it must be such that there is maximum cell survival.
    In 1994, Coleman first described his technique, which uses a syringe, cannula, and centrifuge, for structural fat grafting. He later refined and popularized his technique for fat graft harvesting and processing with the Coleman instruments and centrifuge and a centrifugation protocol, often referred to as the Coleman technique. By using his established technique for fat graft harvesting and processing along with his refined placement technique, many surgeons are able to achieve good long-term results with structural fat grafting.
    This study compared the Coleman technique
    Fat grafts were harvested and processed with the Coleman technique and spun at 3000 rpm for 3 minutes according to his protocol. After centrifugation, both upper and lower levels of components were removed and the remaining fat grafts within syringes were studied subsequently.
    with traditional liposuction harvest
    Fat grafts were harvested with conventional liposuction and spun at 500 rpm for 10 minutes. After centrifugation, the resulting middle layer of adipose aspirates was then studied for comparison.
    Their result:
    In this study, the total number of viable adipocytes was 4.11 ± 1.11 × 106 cells/ml in group 1 and 2.57 ± 0.56 × 106 cells/ml in group 2. The higher viable adipocyte count was found in group 1 compared with group 2. The difference of viable adipocyte counts between the two groups was found to be statistically significant (p < 0.004).
    Glycerol-3-phophatase dehydrogenase assay was used in this study to assess cellular function of fat grafts in each group. The higher the enzyme activity level, the better the cellular function of adipocytes within fat grafts. The glycerol-3-phophatase dehydrogenase activity was 0.66 ± 0.09 U/ml in group 1 and 0.34 ± 0.13 U/ml in group 2. The higher level of the enzyme activity was found in group 1 compared with group 2. The difference of glycerol-3-phophatase dehydrogenase assay between the two groups was found to be significantly significant (p < 0.0001).
    There was no evidence of fatty tissue degeneration or necrosis in either group. Normal structure of fragment fatty tissues was found primarily, and the basic structure of fragmental fatty tissues appeared to be maintained in both groups. No distinguishable differences were seen histologically in group 1 compared with group 2.
    Even though its a small study, it looks like the Coleman method is superior than conventional liposuction for harvesting fat.
    Second article: Fat for Breast: Where are We? (editorial) by Scott Spear, MD (only portions)
    Autologous fat injection in general has achieved wide acceptance over the past decade or two. It is widely used by surgeons for face, buttock, hand, and postliposuction deformities. Its use in the breast has proceeded more slowly, perhaps for good reason. The breast can be augmented or reconstructed in most cases relatively easily with implants or flaps. It is important to remember that for reasons of disease detection, the breast is subjected to frequent radiologic and physical examinations, and greater than 10 percent of women eventually develop breast cancer. Thus, mimicking breast cancer, obscuring breast cancer, or causing breast cancer are issues that surround any breast procedure or device, particularly fat infiltration.
    As we assess the value proposition of breast fat infiltration, we need to distinguish five different scenarios and assess them individually. Those five scenarios are:
    1. Supplementing breast reconstruction by improving contour irregularities.
    2. Correcting defects after lumpectomy or other partial injuries.
    3. Cosmetic breast enhancement and enlargement.
    4. Camouflaging implants after breast augmentation.
    5. Reconstruction after mastectomy using solely fat infiltration.
    As scientific investigations go, we are relatively early in looking into this subject. As we attempt to arrive at our conclusions, I suggest that we measure and examine five factors for each of these potential applications: efficacy, safety, cost, value/work, and liability.
    It seems a strange thing for me to say, but maybe I’m too conservative to embrace this. Here are my concerns:
    Fat necrosis (for example in breast reduction surgery or non-viable fat grafts) can cause changes in a mammogram that may make detection of breast cancer more difficult.
    The time needed for the procedure. Breast augmentation with implants only take me an hour to perform. Breast augmentation with fat is estimated to take five or six hours.
    Results at 6 months/12 months. With implants, the size will be the same at 6 months and at 12 months. Yes, revisions will be needed (see my post comparing saline to gel implants here). With fat grafts, take a look again at the first article -- “The potential for a high rate of absorption over time in the grafted site can be up to 70 percent of the filled volume.” What percentage of these women will need to be re-injected? And how many times will it need to be done? Will each revision take 3-5 hours?
    Cost. Just look at the time difference.
    The average surgeon's fee for implants is about $4,000 and for liposuction about $3,000, according to the American Society of Aesthetic Plastic Surgery. But breast augmentation with fat injections can cost about $20,000, Coleman says.
    I have not even had good long term results with lip augmentation (we’re talking small volume of fat grafts needed), so why should I expect to have them with breast fat grafting? So for now, I’ll stick to what is predictable results for me. I will be watching the studies and techniques though.
    For any woman interested in being in one of the two clinical trials, you can find the information on the federal clinical trials Web site.
    One, led by Scott Spear, MD, chief of plastic surgery at Georgetown University Hospital in Washington, D.C., is seeking 20 women, aged 20 to 50, to undergo liposuction and fat grafting to augment their breasts.
    Another, led by Roger Khouri, MD, a Miami plastic surgeon, will study augmentation with fat in combination with the use of the Brava system. The system includes semi-rigid domes worn over the breasts for several hours a day to induce breast tissue growth before the injections are done.
    Autologous Fat Grafts Harvested and Refined by the Coleman Technique: A Comparative Study; Plast. Reconstr. Surg. 122(3):932-937, September 2008; Pu, Lee L. Q. M.D., Ph.D.; Coleman, Sydney R. M.D.; Cui, Xiangdong M.D.; Ferguson, Robert E. H. Jr M.D.; Vasconez, Henry C. M.D.
    Fat for Breast: Where are We? (editorial); Plast. Reconstr. Surg. 122(3), September 2008, pp 983-984; Spear, Scott L. MD
    Are Fat Injections Safe for Breasts? by Kathleen Koheny; WebMD Health News, Oct 22, 2008
    Cell Survival Theory Versus Replacement Theory; Plast. Reconstr. Surg. 16: 161, 1955; Peer, L. A.

    Wednesday, November 5, 2008

    Nose Bleeds

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

    I am one of those people who have periodic nose bleeds from dry mucosa (and the trauma of blowing my nose – allergies and/or colds).  I have had them since childhood.  There have never been any polyps or other issues noted on the couple of exams I have had.  So I learned long ago how to deal with mine.  I thought I would review some basic information with you.

    The technically correct medical term for nose bleeds is epistaxis.  It is classified on the basis of the primary bleeding site
    Anterior (90% of nose bleeds) 
    • The most common source  if bleeding is from the Kiesselbach plexus which is an anastomotic (think multiple roads coming together) network of vessels on the anterior portion of the nasal septum. (photo credit)
    • May also be due to bleeding anterior to the inferior turbinate.
    • Bleeding will originate from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx.
    • This is much more serious and usually require admission to the hospital and management by an otolaryngologist.

    CAUSES of NASAL BLEEDING (epistaxis)
    Most cases have no easily identifiable cause.
    Local trauma (ie, nose picking, blowing too vigorously, foreign bodies) is the most common cause.  Other local causes include:
    • facial trauma or surgery
    • nasal or sinus infections
    • allergies
    • nasal polyps
    • prolonged inhalation of dry air (climate or too warm house)
    • tumors

    Systemic causes include
    • Blood disorders (hemophilia, leukemia, polycythemia vera, thrombocytopenia, von Willebrand’s disease, etc)
    • Acquired platelet dysfunctions (related to use of aspirin, NSAIDs, dipyridamole, etc
    • Anticoagulation therapy (ie warfarin, enoxaparin, etc)
    • Hypertension is rarely (if ever) a direct cause of epistaxis.  Therapy should be focused on controlling bleeding before blood pressure reduction.
    • Vascular abnormalities that contribute to epistaxis may include the following:
    1. Arteriovenous Malformations
    2. Hereditary Hemorrhagic Telangiectasis
    3. Sclerotic Vessels
    4. Neoplasm (tumor)
    5. Septal abnormality (ie perforation or deviation)
    6. Endometriosis

    As with all bleeding the first thing to do is remain calm, then apply pressure.   How do you apply pressure correctly?
      • Sit up straight.
      • Lean your head forward rather than back.  This way you won’t swallow the blood which can irritate your stomach and make you nauseated.
      • Pinch the nostrils together with your thumb and index finger for 5-10 minutes. Pinch them tightly and don’t let go early.  Yes, it will be uncomfortable if you have enough pressure.  (photo credit)
      • Repeat for another 5-10 minutes, if the bleeding hasn’t stopped.  You may not have held consistent pressure the first time.

    Things that can help prevent a nose bleed or re-bleed:
    • Avoid local trauma.  No nose picking.  Try not to blow your or sneeze for 24-48 hrs after the nose bleed.
    • Minimize exposure to dry air.  This can be a problem if you live in Arizona or in a heated home in the winter.  Adding moisture to the air with a humidifier or vaporizer will help.
    • Using salt water nasal spray can help.   This can be used with abandon, no limits.
    • Using vaseline occasionally to help keep the lining of your nose moisturized.  Don’t overdo this.

    WHEN it’s appropriate to go to the hospital
    • You are still bleeding after REALLY pinching the nose for 10 minutes.
    • You are having repeated episodes of nosebleeds over a 12-36 hour period.
    • You feel dizzy or light-headed or like you are going to pass out.
    • Your doctor instructs you to go to a hospital's emergency department.

    WHEN it’s appropriate to call your doctor
    • Repeated episodes of nosebleeds.  You may need to see a specialist to make sure there are no polyps, etc in your nose.
    • Additional bleeding from places other than the nose, such as in the urine or stool.  You may have a blood abnormality or other health issue.
    • Bruising easily and are not on a blood-thinner.  This may be a sign of another health issue.
    • If you are on any blood-thinning medications, including aspirin or warfarin (Coumadin).  Your doctor should know about your bleeding, as they may wish to change your dosage if you bleed too often or it is difficult to stop.
    • If you have any underlying disease that may affect your blood clotting, such as liver disease, kidney disease, or hemophilia (inability of blood to clot)
    • If you recently had chemotherapy.  Again your doctor should now, so they can check and make sure you aren’t having other issues.

    For anyone interested in more information, may I recommend the following articles.

    Epistaxis by Jeffrey A Evans, MD and Todd Rothenhaus, MD; eMedicine Article; Nov 28, 2007
    Epistaxis by Quoc A Nguyen, MD; eMedicine Article; Nov 29, 2007
    Nasal Pack, Anterior Epistaxis by Eric Goralnick MD and Rick Kulkarni MD; eMedicine Article, Oct 10, 2008
    Nasal Pack, Posterior Epistaxis by Eric Goralnick MD and Rick Kulkarni MD; eMedicine Article, Oct 3, 2008
    Current Approaches to the Management of Epistaxis;  JAAPA May 2003;16:52-64; Richard M Bishow, MPAS, PA-C
    Nosebleeds; eMedicineHealth Article

    Tuesday, November 4, 2008

    Shout Outs

    Mother Jones, Nurse Ratched’s Place, is this week's host of Grand Rounds.   The election edition! You can read it here (photo credit).

    Welcome to Election Day at Grand Rounds. I want to thank Colin and Dr. Val for allowing me to serve as host. I needed the diversion. I don’t know about you, but I’m glad that this election season is coming to an end. Hopefully we will know who our next president is by the end of the night. Pray that no one finds any hanging chads!

    Amanda, This Crazy Miracle Called *Life*, is the host of the current issue of Change of Shift (Vol 3, No 9).   You can find the schedule and the COS archives at Emergiblog.  Go check it out (photo credit)
    We have some fabulous reads today... a few quite creepy to satisfy the occasion and others to make you smile and touch your heart.

    Should you have blogging insurance?  Check out what Dr Wes has to say about it.  It is certainly something to think about.
    I would encourage this given my experience, particularly if "whistle-blowing" or ranting occurs on your blog. Some offerings for bloggers insurance are mentioned here. I'm still shopping options and readers will likely see advertising creep in to my blog to offset expenses.
    I'd also encourage all bloggers to understand the legal definitions of defamation, slander, and libel.

    Correction!  Kat, the Llanview Lowdown, will be the guest on the Dr Anonymous' Blog Talk Radio show this week but on Wednesday, Nov 5thOn Thursday, Nov 6th, his guest will be Mimi Lenox who is founder of the BlogBlast for Peace movement.  Then in a special Friday night show, on November 7th he will welcome Kim from the blog called As The Pump Turns. All shows will start at 8 pm CST or 9 pm EST.  And check out the article in ACP Internist that features Dr A!
    Welcome to the Llanview Lowdown radio show! Your source for everything and anything related to the ABC soap opera, One Life to Live. I am your host, Kat, and I will be chatting with my 2 co-hosts - Sharon, and my webmaster, Mel, every week.
    I hope you will join us this Thursday night at 8 pm CST (or 1 am GMT) both to listen to the show and to participate in the chat room. That's where all the fun is.
    Tips for first time Blog Talk Radio listeners (from Dr A):
    For first time Blog Talk Radio listeners:
    *Although it is not required to listen to the show, I encourage you to register on the BlogTalkRadio site prior to the show. I think it will make the process easier.
    *To get to my show site, click here. As show time gets closer, keep hitting "refresh" on your browser until you see the "Click to Listen" button. Then, of course, press the "Click to Listen" button.
    *You can also participate in the live chat room before, during, and after the show. Look for the "Chat Available" button in the upper right hand corner of the page. If you are registered with the BTR site, your registered name and picture will appear in the chat room.
    *You can also call into the show. The number is on my show site. I'll be taking calls beginning at around the bottom of the hour. There is also a "Click To Talk" feature where you do not need a phone to call into the show - only a microphone headset. Hope these tips are helpful!