Breast Swelling as a Medication Side-effect

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

A patient called last week upset that a drug, domperidone, she has been taking for her GI problems has enlarged her breasts. She had a breast reduction done several years ago (not one I did, I did some scar revision work for her), so this did not make her happy. She came in to talk about redoing her breast reduction. The enlargement is asymmetrical with one being much larger (about 1 bra cup bigger) than the other. This is not a complaint that plastic surgeons hear very often. I was not sure what to tell her regarding insurance. I told her that she will need a mammogram (her yearly is due anyway) to rule out something non-medication related. If the mammogram is normal, I think this will be a case where it would be good to do a pre-approval letter (or medical necessity letter) in advance unless she just wants to take her chances or pay out-of-pocket. It's tough enough getting insurance companies to pay for a breast reduction. Even though legit, I'm sure they will need convinced that a woman might need a second one.

Here are a few more commonly used drugs known to have this side-effect (swollen breasts, breast enlargement, or gynecomastia):
Carbemazepine (TEGRETOL®)
Cimetidine (Tagamet)
Chlorpromazine (Thorazine)
Clomipramine hydrochloride (Anafranil)
Doxazosin (Cardura, Cardura XL)
Dutasteride (Avodart)
Estrogens (including most birth control pills)
Ethosuximide (Zarontin)
Haloperidol decanoate
Methdilazine Hydrochloride (active ingredient in Dilosyn)
Methyldopa (Aldomet)
Metoclopramide (Reglan)
Nilutamide (Anandron^®, Nilandron^®)
Risperidone (Risperdal)
Sustiva (efavirenz, EFV)

Here is a list of drugs (according to the Physician Desk Reference) that can cause gynecomastia as a side effect. The risks are generally very low for male breast enlargement from these medications, but breasts in men can be a cause for embarrassment. [And often women don't mind a small (if symmetrical) enlargement.] Don't forget that some medications may be very important for your other medical problems.

Reduction Mammoplasty

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Breast reduction (or reduction mammoplasty) is an operation designed to reduce and reshape large breasts. It is a surgical procedure designed to help reduce and in many cases eliminate, the pain and other symptoms associated with large breasts. Discomfort associated with large breasts can include chronic back, neck, and shoulder pain, as well as painful shoulder grooves from bra straps. It can also include chronic rashes under the breasts in the inframammary fold. These are the medical reasons to have a breast reduction. Most insurance companies will cover breast reduction surgery done for medical reasons. Be sure to check your policy.

Non-medical reasons may include difficulty finding a bra that will fit. also limit women’s abilities to perform routine daily activities and may cause significant emotional distress. By reducing breast size, breast reduction surgery can relieve many of these symptoms. It can also make it easier to perform routine daily activities and exercise more comfortably.

Some Historic Aspects of the Procedure

In 1922 Thorek introduced the free nipple grafting technique. A significant advance was the introduction of the pedicled nipple-areolar transposition, which improved nipple survival, provided a way to correct ptosis (sagging), and gave a possibility of breast feeding post-reduction (by leaving some of the gland tissue connected to the ducts). Schwarzmann introduced the concept of maintaining the dermal attachments to the nipple as a means of preserving or protecting its blood supply in 1937. This remains important in every procedure used today.

In 1956, Robert Wise published on his experience with a refined pattern that he had previously designed in the form of a key-hole. he emphasized the need for accurate preoperative marking and  provided a pattern for the "key-hole". This Wise pattern has been the workhorse for skin incision for breast reduction for several decades. It leaves an anchor-shaped (or inverted T) scar with a periareolar circle, a vertical scar in the midline of the inferior mammary hemisphere, and a curvilinear scar along the inframammary fold that follows the curved shape of the inferior pole of the breast.

In 1972, Paul McKissock modified Wise's technique by increasing the length of the vertical limbs of the design to try to compensate for the flat lower pole that was being achieved. It is now recognized that McKissock's technique tends to often result in the opposite effect, which is a "bottoming-out" and is not very well tolerated by patients and surgeons.

The vertical scar incision pattern was originally designed by Claude Lassus in 1964 and reported in 1970, with the problem of the inferior portion of the vertical scar ending up extending below the inframammary fold. Lassus corrected this by adding a small horizontal scar along the inframammary fold. Later on, he realized that the small horizontal scar ended up migrating up  toward the lower hemisphere of the breast. He subsequently redefined the pattern of skin excision until achieving one that left only a vertical scar above the inframammary fold. This is the skin incision that is used in the so-called Lejour technique (Madeleine Lejour, MD 1994).  

Each technique has advantages and disadvantages. The superior pedicle method (which involves the resection of the medial, lateral, and inferior portions of the breast tissue) was originally described by Daniel Weiner in 1973. It gained more popularity in Europe, initially, than in North and South America. It was thought to put at risk the sensation of the nipple-areola complex because of the belief that it transected the lateral branches of the fourth intercostal nerve. The sensory branches to the nipple-areola complex are now known to run deep at the level of the chest wall and perforate superficially through the breast tissue to reach to nipple areola complex. For this reason, it is good to keep some tissue on the pectoralis muscle/chest wall as it preserves the nerve supply to the nipple-areola complex and, thus, its sensation.

Today, the tendency is towards Vertical Scar Techniques rather than the ones that use the Wise pattern procedures. However, with truly large (greater than 1000 gm resections) breasts or Grade III ptosis with nipple to inframammary fold lengths greater than 20 cm that is not always possible or advisable. There are times when free nipple grafts are still the best option (safest). 

  

There is also interest in

liposuction reduction mammoplasty. Many insurance companies will not pay for this type of reduction mammoplasty. Liposuction reduction mammoplasty is contraindicated in breasts that are mostly glandular and in the presence of ptosis and/or poor skin elasticity. The only "lift" gained from this type of reduction depends on the skins elasticity.

Complications

In general, postoperative complications are seen more commonly in patients with large resections, obesity, history of tobacco use, and young age. Some evidence suggests that wound dehiscence, fat necrosis, and infection are less common in patients who undergo the Lejour technique than in those who undergo the Wise pattern and inferior pedicle techniques. However, some asymmetry, particularly along the bottom edge, tends to be more common in patients who undergo the Lejour technique; revision rates can be up to 10%. Liposuctioning of the breast has not been shown to increase the rate of local complications

Nipple necrosis

The incidence of complete nipple necrosis is 0.5%. Partial nipple necrosis occurs in a similar percentage of patients.

Infection

As with any surgery, infections can occur. They are not common (0.5-10%) in breast reduction surgery. Most surgeons give perioperative cephalosporins which has been shown to decrease the rate of infections.

Revisions

The revision rate will vary depending on the procedure done (from 1-10%). It may be done for puckers (vertical scar reduction) that may need to be excised

. Puckers are often more of a problem of residual subcutaneous tissue (along the inframammary crease region) than of excessive skin. Or to correct an asymmetry problem. Or to correct hypertrophic scars.
Fat necrosis

Fat necrosis is usually minor and related to what is thought to be parasitic fat along the margins of the pedicle. Minor amounts of fat necrosis can be missed unless the breast is specifically examined for this complication. No treatment is needed except for explanation and reassurance. Patients do not usually require surgery to treat this complication.

Wound dehiscence

Delayed healing may occur and is most likely to be a problem at the inferior end of the vertical incision, where skin gathering is performed in the vertical scar reduction. It is common in the Wise-pattern reductions at the "corners" where the "T" forms. Care must be taken to close the vertical incision loosely and with superficial bites so that the skin is not constricted. This is more common with large reductions and in the obese patients.

Hematoma

Hematomas are usually minor when they occur and can be treated conservatively. It is very rare to have a major hematoma after a breast reduction. Some plastic surgeons routinely use drains. Many of us don't.

REFERENCES
Breast Reduction, Lejour by Antonio Espinosa-de-los-Monteros, MD -- eMedicine Article
Breast Reduction, Simplified Vertical by Elizabeth J Hall-Findlay, MD -- eMedicine Article
Breast Reduction, Inferior Pedicle by Susan E Downey, MD -- eMedicine Article
A preliminary report on a method of planning the mammoplasty; Wise RJ; Plast Reconstr Surg 1956 May; 17(5): 367-75
Breast reduction: evolution of a technique--a single vertical scar; Lassus C; Aesthetic Plast Surg 1987; 11(2): 107-12
Reduction mammaplasty with a vertical dermal flap; McKissock PK; Plast Reconstr Surg 1972 Mar; 49(3): 245-52
Vertical mammaplasty and liposuction of the breast; Lejour M; Plast Reconstr Surg 1994 Jul; 94(1): 100-14
Insurance Coverage: A Patient's Guide -- American Society of Plastic Surgeons Website
Breast Reduction, a Guide for the Patient –ASPS

Medical Blog Awards

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



Thanks for nominating me for the Best NEW Medical Blog Award. I am honored that I have readers. Many thanks to all of you.


Here is the list of the other (very worthy) nominees:
Belaray Dermatology
Canadian Medicine
Corazén Hispano
Dr Shock MD PhD
EverythingHealth
The Happy Hospitalist
MedBlog.nl
NY Emergency Medicine
Update (12-21-2007)
These have been nominated since I first posted this:
Baby blue pyjamas
The Derm Blog
KOLAHUN
The Physician Executive
Unprotected Text
Update (12-26-2007)
More nominations for the Best New Medical Blog 2007 Award:
CareerMedicine
Dr. Val and The Voice of Reason
A fortunate man
Mousethinks
Prudence, M.D.
Respiratory Therapy 101: Just Keep Breathing
TomographyBlog

Marking

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



Marking is very important in both my quilting and my surgery work. I don't mean the kind of marking that gives you "yellow snow" (nod to Frank Zappa) or the kind that leaves you a trail of crumbs to find your way home (Hansel and Gretel).

In plastic surgery, a lot of time can be spent in the preop area marking your patient. So you want a marker that won't wash off so easily that it is gone with the scrub. For breast and body "work", I use (and the nurses tell me so do most of the others) a black Sharpie.

It is marketed as a permanent marker, but I still find that I have to remind the person prepping the patient to not "scrub too hard" or "that's enough". When you have marked the patient standing or bending in different ways to be sure you get the most skin removed, these positions and maneuvers can't be duplicated in the operating room. During the procedure, I use whatever marker the hospital has, usually the Accu-line products. Those are also what I use when I need a really fine line (ie eyelid) when marking.

The skin marker should be nontoxic and non-allergenic. If used during the procedure, then it must be sterilizable. The ink must have a visible color and must be non-reactant  with other chemicals used on the skin (e.g., povidone iodine). The ink must be resistant to mechanical cleaning but removable in time.

The photo to the right is from the first article referenced below. Note how the ink "disappears" with the scrub. Their skin marking ink (1) and frequently used skin markers (2, methylene blue dye; 3, Securline, a surgical skin marker; 4, red permanent marker; 5, black permanent marker; and 6, Viscot, a surgical skin marker). (Center) Skin prepared with povidone iodine solution and scrubbed five times. (Below) Skin prepared with Betadine and scrubbed five times. Their marking ink --The formula consists of basic fuchsin (1.3 g of dye material), 5.6 ml of acetone (resolvent), 11 ml of alcohol (dissolvent), and 100 ml of distilled water. This formula may be diluted by adding alcohol.

In quilting, you want a marker that will stay long enough to see the pattern you are quilting. You want to be able to either "brush" it off gently later (as with chalk pencils) or to wash it out. The different colors of fabrics used can sometimes make this more challenging. For the quilt I am preparing for hand quilting, I used the blue washable marker on the "mustard" (light fabric) and a silver chalk pen on the brown (dark fabric). Here are some links to tips by experts like Ami Simms (blue washable marker), and Sharon Darling (Quilter's Choice Marking Pencil, Miracle Chalk).

REFERENCES
Skin Marking in Plastic Surgery; Plastic & Reconstructive Surgery, 115(5):1450-1451, April 15, 2005; Ayhan, Meltem M.D.; Silistreli, Ozlem M.D.; Aytug, Zeynep M.D.; Gorgu, Metin M.D.; Yakut, Macide M.D.
Quilt Tips From Quilters Around The World--Marking Tips
Appalachian Mountain Quilters Marking Techniques by Kimberly Wulfert

Dan Fogelberg (Aug 13, 1951-Dec 16, 2007)

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

Dan Fogelberg died yesterday, Dec 16, 2007, at his home in Maine after battling prostate cancer. He was "big" in the 70's during my college years, so his music is associated with good memories for me. Please go to the Prostate Cancer Foundation for more information on the disease (diagnosis, treatment, etc).

From his official Web site
Sunday, December 16
Dear friends,
Dan left us this morning at 6:00am . He fought a brave battle with cancer and died peacefully at home in Maine with his wife Jean at his side. His strength, dignity, and grace in the face of the daunting challenges of this disease were an inspiration to all who knew him.
He had a long list of songs (lyrics can be found here), but at this time of year it's the Same Auld Lang Syne always brings tears to my eyes.

SurgeXperiences 111--call for submissions

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

The next edition of SurgeXperiences will be hosted by Buckeye Surgeon on December 23. Please feel free to submit a post (or two) regarding your experience with surgery here. The deadline for submission is December 21st.

The 10th edition of SurgeXperiences has been posted by Dr. Alice over at “Cut on the dotted line”. If you missed it, head on over and check it out.

And since it's the Christmas baking season, in honor of Buckeye, here's a recipe for Buckeye Candy. Enjoy!

Buckeye Candy
Yields - 72 candies (6 dozen total)
The perfect combination of peanut butter and chocolate -- a "chocolate lover's" dream come true....
Ingredients:

• 2 cups creamy peanut butter, (not all-natural)
• 1/4 cup (1/2 stick) butter or margarine, softened
• 3 3/4 cups (16-oz. box) powdered sugar
• 2 cups (12-oz. pkg.) Semi-Sweet Chocolate Morsels
• 2 tablespoons vegetable shortening

Directions:
LINE baking sheets with wax paper.
BEAT peanut butter and butter in large mixer bowl until creamy. Beat in powdered sugar until mixture holds together and is moistened. Shape into 1-inch balls; place on prepared baking sheets. Freeze for 1 hour.
MELT morsels and shortening in medium, uncovered, microwave-safe bowl on HIGH (100%) power for 1 minute; STIR. Morsels may retain some of their shape. If necessary, microwave at additional 10- to 15-second intervals, stirring just until melted.
DIP peanut butter centers into melted chocolate using a toothpick, leaving a small portion of the center uncovered. Shake off excess chocolate and scrape bottom of candy on side of bowl. Return to baking sheets; refrigerate until chocolate is set. Store in covered container in refrigerator.

Christmas Stockings

Here are three Christmas stockings. The front of the stocking is pieced and then quilted prior to being cut and sewn into a stocking. All are fully lined. The first one is a simple four-patch pattern using four fabrics for the "patches".

This one uses two fabrics sewn together into strips. The "cuff" at the top is large

I think it would be nice to have a name embroideried onto it.

This one is a "bow-tie" pattern using two fabrics.

Review of Medical Expenses

My friend who incurred the self-inflicted gun shot wound to his right forearm has gotten his medical bills. I ask him to allow me to review them. I was interested in what was billed and what the insurance company actually allowed. Notice how long it has taken to get everything (well not everything--ambulance services still pending review) through insurance review (late August until today). Here is the breakdown.

Service Rendered		Billed	Insurance Allowed	Patient Responsibility
Ambulance-- ALS Emergency Mileage ALS Pulse Oximetry IV Supplies Disposable Supplies		$488.00 $146.25 $36.00 $42.00 $42.00	* Still waiting	* Still Waiting
Hospital ER		$836.32	$459.98	$459.98
X-Ray Reading		$28.00	$12.18	$12.18
Generic Pain Med		$4.06	$4.06	$4.06
Secondary Wound Closure (done in office)		$650	not actually billed (maybe $356 on hosp % reimburse)	not actually charged (maybe $356 as based on ER reimbursement)
At home dressing supplies		not covered by insurance $30.06	not covered $30.06	$30.06 (Coban, guaze, etc)
Total Expenses		$2,302.69	$862.28*	$862.28*

My friend has a Medical Savings Account so has a high deductible ($5700). The insurance coverage did decrease his actual out-of-pocket responsibility by "not allowing" $392.16 (more depending on the ambulance bill outcome). This is also money that the hospital and ambulance service did not receive. I know he is grateful for the savings. I, however, also see the other side. A reduction of nearly 50% seems absurd. Is the medical community really overcharging that much? Or are we charging fairly to cover the expenses of the hospital/office? Just as Wal-Mart has a built in "padding for loses" for each item sold (covers losses due to theft /shop lifting), the hospitals/offices need to be able to have the same "padding" to cover the services that aren't paid for by the patient (under-payment by Medicare/Medicaid, no insurance, simply doesn't pay, etc).

Panniculectomy vs Abdominoplasty

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


I posted this information back in July, but I thought it would be worth sharing again. As the number of gastric bypass and lap band procedures increase, the number of patients who need this information just continues to grow.

You’ve had your gastric bypass and have lost over 100 lbs. Now you have "all this loose, saggy skin that just hangs" and you have "rashes under the fold all the time". Will your insurance pay for a tummy tuck? Probably not what you are thinking of as a tummy tuck. They may pay for a panniculectomy, but not an abdominoplasty. So let me try to tell you the difference between the two. Photo from article (see below).

Panniculectomy is the removal of the loose (excess) skin and fat tissue below the belly button (umbilicus). Nothing is done to the (possible/probable) loose skin above the belly button. It is strictly to help remove the overhanging skin that is trapping moisture and creating a hygiene and chronic rash problem. It is not meant to improve your overall body shape.

An abdominoplasty is the removal of the loose (excess) skin and fat tissue from the abdomen (stomach area) with transposition of the skin around the umbilicus (the belly button doesn’t usually get moved, the skin around it does) and often tightening (plication) of the abdominal muscles. This creates a more pleasing shape as it addresses the entire abdomen. It is not just a functional surgery, but a cosmetic one.

Look at the above photos. The one on the left with minimal upper body excess skin might get both the functional and improved body shape (cosmetic result) with the panniculectomy. The one on the right would still have the "upper" skin roll as this is from skin above the umbilicus. So by definition, the panniculectomy would not do anything to improve this. The insurance company (see the California BC restrictions) would probably not be persuaded to make an exception for a full abdominoplasty which is what she would need. Chances are this person gets skin irritation below the upper roll also. Frustrating, isn’t it?

Prior to this year (2007) when a surgeon coded the surgical procedure for a panniculectomy or an abdominoplasty the same code was used. This made it difficult (without reading the operative note) to truly tell what had been done.
CPT 15831 Excision, excessive skin and subcutaneous tissue (including lipectomy);abdomen (abdominoplasty)

As of this year the coding has changed which makes it more clear to an insurance company what has been done for the patient. Perhaps it will also help clarify for the patient that a "cosmetic tummy tuck" is not what they will get (unless they are willing to pay the difference) when a panniculectomy is done. The new codes are:
CPT 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
CPT 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)
Use 15847 in conjunction with 15830

To know whether your insurance policy will help you out with this issue, check your policy or call your insurance provider. Here is BC of California’s policy on the issue. Here is Cigna's. Many insurance companies have similar policies. Some consider it all cosmetic.

Photo--A Classification of Contour Deformities after Bariatric Weight Loss: The Pittsburgh Rating Scale; Plastic & Reconstructive Surgery. 116(5):1535-1544, October 2005; Song, Angela Y. M.D.; Jean, Raymond D. M.D.; Hurwitz, Dennis J. M.D.; Fernstrom, Madelyn H. Ph.D.; Scott, John A. M.S.; Rubin, J Peter M.D.

ASPRS Recommendations for Third-Party Payers--Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients

My First Award

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



Yesterday, I was given the ‘Be The Blog‘ award…

…created by Mark at Me and My Drum for bloggers who make their blog their own, stay with it, are interactive with their readers, and just plain have fun. I was given the award by ScanMan. I understand this is not a meme. I have I found the space in my sidebar and but Vijay has picked the friends who are inextricably linked to their blogs and to whom I would pass it along. I hope that don't mind being nominated twice.

Moof (All Blogged Up -- A Moof's Tale)
Lakshmi (I Think--too much)
Enrico (Mexico Med Student)
Rob (Dr Rob)
Bongi (other things amanzi)



To this list I would add a few quilting bloggers
Jude (Spirit Cloth)
Kate (Kate's Quilting Blog)
Penny (Penny Sanford)
Thank you Vijay.

Pay Telephones

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

In the local paper this weekend there was an article on the declining use of pay-phones. It seems that Bell System plans to get out of the pay-phone business after 129 years. It included a nice summary of the history of pay-phones. Here is the time line:

1878: The first pay phone has an attendant who takes the caller's money.

1889: The first public coin telephone is installed by inventor William Gray at a bank in Hartford, Connecticut. The phone is a "post-pay" machine where coins are deposited after the call is placed.

1898: The Western Electric No 5 Coin Collector goes into use in Chicago, Illinois. It is the first automatic "prepay" station. Coins are deposited before placing the call.
1902: There are 81,000 pay telephones in the United States.
1905: The first outdoor Bell System coin telephone is installed on a Cincinnati street.
1950s: Glass outdoor telephone booth begin replacing the wooden ones.
1957: Drive-up pay telephones are tested in Mobile, Alabama and Chicago, Illinois.
1960: The Bell System installs its millionth pay telephone.
1966: "Dial tone first" service is introduced in Hartford, Connecticut. Emergency calls could now be made without first depositing coins.
Feb 2, 2001: BellSouth announced that it is getting out of the pay-phone business.
Dec 3, 2007: AT &T Inc announces plans to leave the pay-phone business.
Today: There are about 1 million pay phones, down from 2.1 million in 1998. Local calls on pay phones have also dropped 30% since 1998.

I must admit that I can not recall the last time I used a pay phone. I think it was back in the early 90's prior to getting a cell phone. It seemed I could never find change when I needed to answer my pager, so I quickly got a cell phone. I miss the wooden phone booths you could find in restaurants. There was an elegance to them. The outdoor phone booths reminded my of Superman, so I miss them too.

I can't recall treating anyone from injuries that incurred from use of a phone booth, but I can imagine a few that probably happened. Whenever there is a door, there is a hinge and this means fingertip injuries. The phone booths out in the open are, of course, likely to be hit occasionally by motor vehicles. And as with any land-line phone, it was important not to use the phone during a lightning storm. If you have any to relate, I would love to hear about them.

Telephone injuries associated with lightning:

• Injuries to persons using telephones or telephone headsets, such as those who take phone orders, are relatively common. The telephone becomes the conduit for the charge to enter or to escape from the structure (and the person). Although the telephone system may be grounded adequately for electrical surge protection, lightning is too fast and strong for typical grounding systems to be effective and reaches the person before the circuit breaker or other protection can be effective.

• Electrical lightning damage occurs only with use of land-line phones. No lightning danger is inherent to cellular phones. Although many reports of lightning injuries involve people who are using cell phones, these reports represent the ubiquity of cell phone usage and of their users' inattentiveness to weather conditions and have nothing to do with the phones themselves.
• Older portable phones, seldom used now in the United States, were a rare source of lightning injury to people standing close to the base station or charger. Those injuries were caused by the lightning jumping from the charger to anything close by and have little to do with the phone the person was carrying.

References
Pay Phones and Phone Booths -- Bell System Memorial
Lightning Injuries by Mary Ann Cooper, MD -- eMedicine Article

50-Minute Strength Workout

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


Yes, I am a member of AARP. My husband turned 50 last year and I did this year. The picture below is from the latest edition of the AARP Bulletin. The article, "The 50-Minute Strength Workout", suggests putting aside 50 minutes a week--two days of 25 minutes each. I would add, if that seems too hard, then try 5-10 minutes each day, rotating the exercises you do so that each muscle group gets used.
Remember that for most of our "life" activities, we need to keep those muscles strong. I know that for myself (I had an anterior cervical fusion, C6-7, done over 15 years ago), doing my pull ups (under-handed chin ups) and push-ups helps me perform surgery and carry groceries (as many bags as I can at one time) with fewer muscle aches in my neck and shoulders. I can tell the difference if I miss too many days. These are exercises I can do at home, as my husband put a chin-up bar in my closet doorway for me. They only take a few minutes.

We all know that these activities will help us:

• build strength


• maintain bone density (important for both women and men)


• improve balance, coordination, and mobility


• reduce your risk of falling


• maintain independence in performing activities
  of daily life.

The old saying is true when it comes to muscle: “Use it or lose it.” The first reference listed below, Growing Stronger--Strength Training for Older Adults, is a very nice "book" that will walk you through all the exercises.
Some exercises need no equipment.
S Q UAT SA great exercise for strengthening hips, thighs, and buttocks. Before long, you’ll find that walking, jogging, and climbing stairs are a snap!
1. Stand directly in front of a sturdy chair. Your feet should be slightly
more than shoulder width apart. Extend your arms so that they are parallel to the ground.
2. Place your weight more on your heels than on the balls of your feet. Bend your knees as you lower your buttocks towards the chair in a slow, controlled motion, while you count to 4.
3. Pause. Then, slowly rise back up to a standing position as you count to 2. Keep your knees over your ankles and your back straight.
Repeat the squat ten times. This equals 1 set. Rest for about 1 minute. Then complete a second set of 10 squats.
WA L L P U S H - U P SThis exercise is a modified version of the push-up you may have done years ago in physical education classes. It is easier than a push-up and you don’t need to get down on the floor—but it will help to strengthen your arms, shoulders, and chest.

1. Find a wall that is clear of any objects such as wall hangings and windows. Stand a little farther than arm’s length from the wall. Face the wall, lean your body forward and place your palms flat against the wall at about shoulder height and shoulder-width apart.
2. Bend your elbows as you lower your upper body toward the wall in a slow, controlled motion as you count to 4. Keep your feet planted.
3. Pause. Then, slowly push yourself back until your arms are straight as you count to 4. Make sure you don’t lock your elbows.
Repeat the wall push-up 10 times for 1 set. Rest for about 1 minute. Then do a second set of 10 wall push-ups.

Other exercises will need weights--these can be actual weight or a bottle of water (half-full or full).
BICEPS CURL

This one will help that gallon of milk feel a lot less heavy.
1. Stand or sit in a chair with a dumbbell in each hand. Your feet should be shoulder-width apart with your arms at your sides and your palms facing your thighs.


2. Rotate your forearms and slowly lift the weights as you count to 2. Your palms should be facing in towards your shoulders. Keep your upper arms and elbows close to your side—as if you had a newspaper tucked under your arm.
3. Pause. Then, slowly lower the dumbbells back towards your thighs as you count to four. Rotate your forearms so that your arms are again at your sides, palms facing your thighs. Repeat 10 times for 1 set. Rest for about 1 minute. Then complete a second set of 10 repetitions.


For more exercises check these references and live strong:

Growing Stronger--Strength Training for Older Adults (pdf file from the CDC) and More Exercises

Strength Training for Women

Balance, stretching and strength training -- Mayo Clinic