A Lot of Hot Air?

There is an article in the Cosmetic Surgery Times Vol 11 No 5 2008 on the subcutaneous injection of carbon dioxide (CO2). The treatment is called carboxytherapy.

Subcutaneous injections of carbon dioxide (CO₂) can safely and successfully treat cosmetic concerns such as skin laxity and fatty deposits that may remain following liposuction, as well as psoriasis and hair loss, says an expert based here. Additional uses for this treatment — called carboxytherapy — include stretch marks, scars and cellulite, he says.

This is the first time I have ever read or heard of carboxytherapy. So I did a search using carboxytherapy on Medscape -- no articles. I searched the database of the Journal of Plastic and Reconstructive Surgery -- no articles. I changed the search to carbon dioxide/ subcutaneous injections and got this one relevant hit:

• Carbon dioxide therapy in the treatment of localized adiposities: clinical study and histopathological correlations. Aesthetic Plast Surg, May 2001

I didn't do any better with a google search. At least not for scientific information. So back to the CST article, here is a description of carboxytherapy:

I've been using this technique for more than a year, and getting fantastic results," says Raphael Nach, M.D., a head and neck surgeon in private practice. He estimates that he has treated at least 40 patients for post-liposuction problems such as persistent islands of fatty tissue, skin irregularities and skin laxity. Dr. Nach explains that by adding CO₂ gas to the subcutaneous tissues, localized post-operative accumulations of fat can be reduced or eliminated." Alternative forms of treatment have been advised to assist the general recuperate process," he says, "but none have been as successful in eliminating these localized fatty deposits."

TECHNIQUE IN BRIEF The technique requires no anesthesia. First, one sterilizes the skin with Hibiclens (chlorhexidine topical antiseptic; Mölnlycke Health Care U.S., Norcross, Ga.) or its equivalent, he details. "Then a 30-gauge needle connected to the carboxytherapy machine is used to infiltrate the tissues with different volumes of carbon dioxide gas, depending on the condition that's being treated," Dr. Nach explains. A typical treatment site requires about 50 cc to 200 cc of gas, injected either once or twice a week, he says. Each session lasts 15 to 20 minutes. Depending on the treatment area, he says, four to six puncture sites with the 30-gauge needle may be necessary.

I found some references that state that this procedure is FDA approved (including Dr Nach), but according to the ASPRS website (2008) it isn't.

Carboxytherapy
Injection of carbon dioxide for cosmetic purposes, namely to treat cellulite. Not U.S. FDA approved.

I then tried a search of the FDA website and got no hits on carboxytherapy or carbon dioxide/ cellulite.

So for now I would suggest being very skeptical of any claims that carboxytherapy would improve anything. Dr Oliver or anyone else have any information on this? Preferably scientific information.

Grand Rounds 4:38 is Up

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

Grand Rounds is up across the pond at NHS Blog Doctor. Dr. Crippen begins this edition with

Dr Crippen was particularly addicted to ER as are a lot of British doctors. What would Mark do? we always asked when there was an emergency. Sadly, suddenly Mark was no longer with us. Medical life has not been the same since.

My favorite character of that show ER was always Dr Peter Benton. The show lost it's appeal for me when he left the show.

Ian Furst, Wait Time and Delayed Care, feels that Dr Crippen left out his (Dr. Crippen's) own post on Dr. John Briffen. Ian feels it is a must read. It is an interesting post.

Thanks to Dr. Crippen for putting all these "good reads" together for us.

And don't forget to listen to the Dr Anonymous Show tomorrow night at 8 pm CST/ 9 pm EST. His guests this week will be David Best, MD and Michael Banks, MD from The Doctors Channel. Come join us in the Chat Room which is always fun.

My Friend Lisette

Late Friday night, June 6, 2008, my friend Elizabeth "Lisette" Marie Columbo Johnson lost her fight with ovarian cancer. She was only 56 yo. I meet her in the OR where she was a surgical nurse. I loved working with her. She was good -- as a person, at her job, to the patients, to her colleagues. She was beautiful. She was so full of life and shared her passions with us in stories.

She loved that I had named my dog Columbo. "That's my maiden name." She would often ask about him and my other dogs. She had a black Labrador when we first met so we shared many dog stories. At some point a roadrunner took up residency near her home. The bird would visit her deck. She brought in pictures of the roadrunner just sitting on a deck chair for us.

She loved to travel (India, Russia, Africa). I loved her travel stories and pictures. I would have loved to have been a team member with her on "Amazing Race". She would have made me more adventurous.

From her obituary:

Lisette was born in Darby, PA and graduated from the University of Pennsylvania. She spent most of her career as a surgical nurse in Dallas and Little Rock. In Dallas she was active in charity work and was a past Chairman of the Multiple Sclerosis Society’s Yellow Rose Gala.

She was an avid outdoors enthusiast, animal advocate, sporting clay shooter, traveler and mah-jongg player.

She touched the lives of many and was an inspiration to us all. She will be dearly missed. In lieu of flowers, please make a donation to the Ovarian Cancer Research Fund or the ASPCA.

For more information on ovarian cancer:
National Cancer Institute -- Ovarian Cancer Page
Center for Disease Control -- Ovarian Cancer
Ovarian Cancer Awareness Organization
Ovarian Cancer Symptoms --TBTAM

Hi!

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

Dr Rob's recent post, Hi Doc! got me musing about my encounters with patients outside of the office. Very often the reactions to a plastic surgeon aren't the same as the reactions to the family physician.

I get some who readily want to acknowledge that they know me. This can be in the "groupie/fan" kind of way or "friend (want-to-be)" kind of way.

The "fan" is happy to tell anyone who is present "This is the doctor who did my breasts. They are just perfect. Dr Bates' is the one I've been telling you to go see." This one I sometimes enjoy, even though I often am embarrassed by their gushing. I have had to stop a few of these from showing off their scars in the store. One even offered to show my husband "my work" (which I did not allow).

The "friend" -- "Hi Ramona. JB, this is my plastic surgeon. The one who did my scar. She's the one we need to go see for our BOTOX." In the back of my mind, I can't help wondering if this one is "fishing" for a discount for bringing me business.

Then there are the ones who don't want to acknowledge they know me professionally. "Didn't I meet you at that charity event?" "I remember meeting you at C and D's." I try to play along without resorting to bald-faced lies. They don't want whoever is with them to know they have seen a plastic surgeon. They might have to explain why.

There are some who don't even want to acknowledge they have met me in any capacity. You can see the fear in their eyes begging "don't know me, don't know me". These I will just smile at and once again taking their lead take the "friendly stranger" interaction. They really don't want anyone to know they have seen a plastic surgeon. They can't think of any other reason they should know me to give to their friends/colleagues. The one I remember the most was a young reporter years ago. I had done a breast reduction for her and happened to see her in a store where she was setting up to broadcast a report.

For this last patient, it helps that I don't really look like most peoples idea of a plastic surgeon. In fact, if I was to be on the game show, Identity, I would probably be a stumbling block for most. When you run into me at Wal-Mart of Kroger, I will often be in jeans or shorts and look like I could use Stacy and Clint's help with my wardrobe.

I'm happy to acknowledge you if we meet in the public eye, but if you don't want to acknowledge me that's okay too.   If you do want to talk to me, let's try to keep it social.  Remember I'm "off work".  As Lynyrd Skynyrd puts it "if you want to talk fishin, I guess that'd be okay"  or in my case dogs or quilting.

SurgeXperiences 123

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

SurgeXperiences 123 is up over at The Sand Man. QuietusLeo has done a great job. You can read it here.  It represents the fact that he is a Leo and puts people to sleep (anesthesiologist) for a living.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The 24th edition will be be hosted by , (host still needed), on June 22nd. The deadline for submissions will be June 20th. Please submit your posts here.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Dog Bite Prevention

Once again I missed National Dog Bite Prevention Week. It's the third full week of May and it's already the end of the first week of June. I don't think it ever hurts to review this information as more than 4.7 million people a year receive bites from man/woman’s best friend and I dearly love my dogs -- deceased ones (Columbo, Ladybug (photo), and Girlfriend) and the living one, Rusty.

Many cities and towns across America are beginning to restrict by out-right ban or by registration of certain breeds. In Little Rock, a new city ordinance requiring all pit bulls in the city to be registered, sterilized, and microchipped took effect. This ordinance was passed because of an increase in attacks which are said to be unprovoked.

The following is a re-posting of my Dog Bite Prevention post from last June. Maybe next year I'll get one published on during the third week of May.

Each year, nearly 1 million Americans seek medical attention for dog bites; half of these are children. Most dog bite-related injuries occur in children 5-9 years of age. Almost two thirds of injuries among children 4 yrs or younger are to the head or neck region. Dog bites are a largely preventable public health problem, and adults and children can learn to reduce their chances of being bitten.

Basic safety around dogs:
• Do not approach an unfamiliar dog.
• Do not run from a dog and scream.
• Remain motionless (“be still like a tree”) when approached by an unfamiliar dog.
• If knocked over by a dog, roll into a ball and lie still (“be still like a log”).
• A child should not play with a dog unless supervised by an adult.
• A child should immediately report stray dogs or dogs displaying unusual behavior to an adult.
• Avoid direct eye contact with a dog.
• Do not disturb a dog who is sleeping, eating, or caring for puppies.
• Do not a pet a dog without asking permission from its owner first.
• Do not pet a dog without allowing it to see and sniff you first.
Things to consider before adding a dog to your household:
• Learn about suitable breeds of dogs for your household.
• Dogs with histories of aggression are inappropriate in households with children.

• If your child is fearful or apprehensive around dogs, then don’t get one. it will not make the child less fearful.

• Spend time with a dog before buying or adopting it. Use caution when bringing a dog into the home of an infant or toddler.

• Spay/neuter virtually all dogs (this frequently reduces aggressive tendencies).
• Never leave infants or young children alone with any dog.
• Do not play aggressive games with your dog (e.g. wrestling).

• Properly socialize and train any dog entering the household. Teach the dog submissive behaviors (e.g. rolling over to expose abdomen and relinquishing food without growling.

• Immediately seek professional advice (e.g. from veterinarians or animal trainers) if the dog develops aggressive or undesirable behaviors.

Snail's Trail Quilt

This quilt pattern is different from the previous snail's trail quilt I made. This quilt is for a friend. I picked out the colors with "I like earth colors" in mind. So in my mind the browns are obviously for the earth. The green for the grasses and trees of the earth. The blues for the rivers, lakes, and oceans. The reds/pink for the sunrises and sunsets.I debated with myself on which layout I liked best. Each block is 5 in square (finished, 5.5 in with seam allowances).

Here is the finished quilt. It is 40 in X 50 in. Each of the arc pieces are machine pieced and then hand appliqued to a square. The squares were then machine pieced. The machine quilting is overlapping circles in a variegated brown.

Here is a closer shot. I mailed the quilt earlier this week.

High Pressure Injection Hand Injuries

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

Thankfully high-pressure injection injuries to the hand are uncommon because they have the potential to cause devastating consequences. To complicate things, these injuries often look innocuous with their initial presentation. Despite this innocuous looking injury, these accidents should be treated as limb-threatening injuries and immediately referred to a hand surgeon.

The three most common devices responsible for these injuries are:

1) grease guns -- A force of 100 to 200 psi (pounds per square inch) is generated by air compressors to propel the grease through the lubricating mechanism. The actual force is amplified by a pump and a reducing nozzle, so that a pressure of 5000 to 10,000 psi is generated.

2) spray guns -- A hydraulic pump forces paint through the spray gun at pressures up to 5000 psi.

3) diesel fuel injectors -- Pressures from 2000 to 6000 psi

The most commonly injected substances are automotive grease, diesel oil, paint, and varnish. Other substances reported include paint thinners, oil, molding plastic, cement, wax, air with rust, water with sand, and sealers (ref 6). There are reported injuries due to the solvents (ref 4) in the garment dry cleaning industry (isoparaffinic hydrocarbons, methoxypropanol, and dichlorofluoroethane) and also with Freon. Typically, paint and paint thinner injuries have much worse outcomes than grease gun injuries.

Injuries occur most often in men. The left hand (usually the non-dominant) is involved in nearly 2/3's of the cases. The most commonly injured site is the index finger, followed by the palm and the long finger. Direct contact with the skin is not necessary for injury. The jet may penetrate through gloves and other protective garments.

Mason and Queen in 1941 divided the clinical findings into three states:
Acute --

• The immediate symptoms result from the injection of the foreign material are swelling, numbness, and vascular insufficiency.
• This distention of the tissues may cause a pressure buildup that exceeds hydrostatic pressure, limiting tissue perfusion similar to that in compartment syndrome.
• The chemical injury caused by the substance itself may result in tissue destruction and an inflammatory reaction (which leads to more swelling, which may further compromise the tissue perfusion)
• Infection may occur in the necrotic tissue or from contamination from the substance injected.
• Initially, the patient may complain only of mild pain and may even continue working, leading to a delay of care. The injured area may at first seem inconspicuous, presenting as a small pinprick, and caregivers who may not be familiar with this injury may regard it as insignificant. The finger eventually becomes painful, numb, bloated, edematous, tense, pale, and cold.
• Radiographs may help assess the extent of the spread of the injected material, which may present as air in the soft tissue, or as radiopaque material in other cases.

Intermediate

• Oleomas often develop following the acute phase. These are nodular "tumors" that develop as a result of a foreign body reaction to the injected material.
• Oleomas may remain unchanged for years, but fibrosis often occurs with them, leading to loss of function. Because of this, oleomas should be excised completely along with any fibrosis associated with them.

Late

• Skin overlying the untreated oleoma may breakdown. This may lead to ulcer and draining sinus formation.
• The skin becomes thick and pitted.
• The ulcers and draining sinuses may become infected.
• Development of squamous epithelioma in the sinuses have been reported.

The following guidelines are suggested for optimal treatment:
1. Early medical evaluation, including radiographic studies.

2. Prompt surgical consultation. Patients treated properly within 10 hours of injury had much better outcomes than those treated in a delayed fashion.

3. Administration of tetanus prophylaxis and intravenous antibiotics.

4. Elevation and splinting before and after surgical exploration. Do not use cooling packs to control edema because their use may further compromise tissue perfusion.

5. Surgical exploration using general anesthesia or axillary block. Digital and local blocks may contribute to tissue edema and are associated with worse outcomes.

6. Use of an extremity tourniquet to establish a bloodless operative field after exsanguinating the arm by elevation. Esmarch bandage exsanguination may cause further spread of the injected toxins into tissue planes or compartments.

7. Wide surgical exploration, including decompression of tissue compartments, debridement of nonviable tissue, and high-volume saline irrigation. Particular attention should be directed toward fluid tracking around neurovascular bundles. Flexor tendon sheaths are less likely to be involved.

8. Wound cultures when appropriate to direct antibiotic therapy.

9. Consider leaving the wound open, with a planned second look operative irrigation and debridement.

10. Consider early amputation of a cool or poorly perfused digit.

11. If edema is significant, consider administering 100 mg of hydrocortisone intravenously every 6 hours until improvement is observed. Change to 25 mg of oral prednisone daily and taper over 3 to 5 days. Restart hydrocortisone if edema, erythema, or pain worsens. [Controversial.]

12. Frequent postoperative reassessment and return to the operating room if indicated.
13. Early postoperative hand therapy to maximize functional outcome.
Prevention of these injuries is the best.


REFERENCES

1. High-Pressure Injection Injuries of the Hand; Plastic & Reconstructive Surgery. 45(3):221-226, March 1970; Ramos, Hernando M.D.; Posch, Joseph L. M.D.; Lie, Kim K. M.D.

2. Conservative management of a high pressure injection injury to the hand; Plastic & Reconstructive Surgery. 72(5):742, November 1983; Kelleher, John C.; Kendrick, R. W; Colville, J.

3. UPPER EXTREMITY: Emergency management of high pressure injection injuries of the hand; Plastic & Reconstructive Surgery. 83(2):403, February 1989; El, Helaly M.; Beheri, Gamal E.

4. High-Pressure Hand Injection Injuries Caused by Dry Cleaning Solvents: Case Reports, Review of the Literature, and Treatment Guidelines; Plastic & Reconstructive Surgery. 111(1):174-177, January 2003; Gutowski, Karol A. M.D.; Chu, Jason M.D.; Choi, Mihye M.D.; Friedman, David W. M.D.

5. Long-Term Follow-Up of High-Pressure Injection Injuries to the Hand; Plastic & Reconstructive Surgery. 117(1):186-189, January 2006; Wieder, Anat M.D.; Lapid, Oren M.D.; Plakht, Ygal M.Med.Sc.; Sagi, Amiram M.D.

6. High Pressure Injection Injuries; Hand Clinics 2 (3), 1986: pp 547-552; B Thomas Harter Jr MD and Kathleen C Harter MD

7. Grease gun injuries to the hand: Pathology and Treatment of Injuries (oleomas) following the injection of grease under high pressure.; Quarterly Bulleting of Northwestern Medical School, 15:122, 1941; Mason, M. L. and Queen, F. B.

8. High-Pressure Injection Injuries; eMedicine, Feb 19, 2008; Jugpal S Arneja MD and others

Some Shout Outs

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

Just wanted to link to some posts and information I found interesting.

First off Happy Hospitalist did a grand job using the Six Degrees method linking the posts of Grand Rounds 4:37 to himself. Check it out.

Second If you don't know about the SixDegrees.org, the charity charitable initiative that Kevin Bacon started in partnership with Network for Good, you may want to check it out. Either make your own charity badge (see mine on the left side-bar, bottom) as I raise money for the Arkansas Food Bank. Or add your charity to the Network for Good list.

Third Paul Levy posted "Terrorism Near and Far"

A riveting presentation today to our Board of Overseers. First was Diane Covert, freelance photographer and creator of "Inside Terrorism: The X-Ray Project". This is an exhibit which uses actual X-rays and CT scans from two large hospitals in Israel to explore the effects of terrorism on a civilian population.

Fourth Did you see this post at MedGadget on the New Luke Arm? Wow, I wish I could have helped develop this (wish I was smart enough). I always wondered if we would get to this point during my life since watching the Six Million Dollar Man as a kid. Wow!!!

Fifth Check out the x-rays of the Appendicolith over at Scalpel. I don't recall ever seeing one as large or as clear as this one. Impressive!

Sixth Dr Rob Oliver, Plastic Surgery 101, has a nice post on Malignant Hyperthermia and the recent patient death in Florida.

Seventh Fat Doctor's son had to have eye surgery this week. She shares the video of the surgery with us here.

Eighth Did you catch this "My Bloodsucking Visit to a Leech Clinic" posted May 23, 2008 by Canadian Medicine? [via Kevin,MD] Let me refer you back to my post on Leeches.

Ninth Don't forget that tomorrow night, Dr Anonymous will be hosting Dr Gwenn O'Keeffe on his Blog Talk Radio show.

Tenth And the "Peace Globe Movement" in the blogosphere. This is a simple idea brought forth by Mimi Lenox back in the fall of 2006. Mimi was even a guest on The Doctor Anonymous Show Number Eleven back on October 25, 2007.

Tick Prevention

I wanted to share a tip with you on getting rid of the tick you find crawling on yourself. My husband taught me this. When you see the tick or have pulled it off, get a piece of Scotch tape and apply it to the tick. You can then place the tick into the trash without fear of dropping it onto your floor. It will also get rid of the need to flush the tick down the toilet, and thus save water.

Now here is the post on ticks I did almost a year ago with a small addition.

Having been outside more lately, as the weather has gotten so much nicer I have also noticed more ticks. I believe that prevention in medicine is to the act of doing something (change diet, not smoke, use condoms, etc) to avoid the need for treatment of a disease (heart disease, emphysema, HIV). So I would encourage all or you to take the proper steps to prevent Lyme's Disease and avoid the need for treatment. The "preventive" steps to take are to either avoided the tick-invested area or used a DEET or permethrin-based tick repellent and then doing a body check for ticks that same evening.

• According to the Center for Disease Control it takes 36-48 hrs for transmission of B.burgdorferi or B. microti to occur from an attached tick and not all ticks are infected. Therefore, a tick bite does not necessarily mean a person will get infected. Prompt removal of the attached tick will reduce the chance of infection.
• Tick paralysis is rare. One reason the condition is so unusual is that the tick must be attached for five days before symptoms develop. So do a daily tick check of yourself and your children if you live or visit an area that has ticks. (reference below) [This section added as well as the references.]

I walk my dogs daily in the woods nearby. My dogs are protected with Frontline. I use Deep-Woods Off and often wish I could use Frontline. That would be so much simpler, apply once monthly. Don't forget the sunscreen and wide-brimmed hat.

Protect yourself, then get outside and enjoy life!

REFERENCE

Six Case Studies in Potentially Life-Threatening Weakness; Emergency Medicine, May 2008, pp 25-30; Scott C Sherman MD

Eye Patches

Recently one of my blog friends mentioned the need for a Latex free eye patch. She has double vision from her myasthenia gravis. She has a Latex allergy. My local stores don't care any latex free eye patches. The elastic has latex, so the readily available ones won't work for her. I bought one of the eye patches (less than $2) to use as a pattern. I don't know her size, but using myself I tried it on and trimmed it until it was "comfortable". This then became my pattern.

I had some Ultrasuede scraps that I used for the patches which I stiffen with a heavy-weight iron-on backing. To protect her from the elastic, I covered the 1/8 in elastic with 1/4 in double folded bias tape.

I am going to mail her the "pattern" and some extra supplies along with the two finished eye patches. She has mentioned a friend near her that sews. So if she wants more, maybe that friend can make them for her. Especially, if these two don't fit properly.

I tried to get Rusty to model the patch, but he didn't like having it over his eye. Bless him, he did allow this photo.

If you don't want to make your own, but would like something other than the basic patch found in most stores try the links found here on the message board of the American Foundation for the Blind.

SurgeXperiences 123 Call for Submissions

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

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The 23rd edition will be be hosted by QuietusLeo, The Sand Man, on June 8th. He is an anesthesiologist in Israel.

In case you were wondering - "QuietusLeo" is latin for "sleeping lion" (I think). Obviously, I was born a leo. The connection seems to make sense.

The deadline for submissions will be June 6th. Please submit your posts here. Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.