SurgeXperiences 301 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Updated 3/2017-- all links (except to my own posts) removed as many no longer active.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 1st edition of SurgeXperiences’ third season is hosted by Buckeye Surgeon.  You can read this edition here.

Welcome to another tardy edition of SurgeXperiences! It's been a killer week for me so this is probably going to be a little substandard. Apologies will be forthcoming. Operating three nights in a row after 2AM while your partner is out of town will do that to you. So excuse the spelling errors, the fractured syntax, the incoherence, the lack of any semblance of organization. Which seems to fit perfectly in the context of the former Alaskan governor's rambling resignation speech....So here it goes, just follow the damn links.

Quilt Top for Steve and Lori

This quilt is in progress.  It is for my brother Steve and his wife Lori.  I finished the top in mid-June.  It measures 56 in X 76 in.  I could quilt it, but would end up with major neck and should spasms as I use a simple sewing machine to do my machine quilting.  I have contacted a friend with a long-arm quilting machine whom I will pay to do the quilting.

The block pattern is one I have used before – Alabama quilt block.

Here is a detailed photo of the fabrics.  You can see the turquoise blue dots in the dark chocolate brown fabric here.

I’ll share the quilt with you once it is finished.  My friend is backed up a month or two.  I will need to do the binding once the quilting is done.

Use of Zafirlukast for Capsular Contracture

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.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 first read of the off-labeled use of zafirlukast back in 2002.  I had one patient with a unilateral Baker’s Grade IV capsular contracture who wanted to avoid surgery (open capsulectomy).  I told her it wasn’t proven (only 30 patients) but that half experienced softening of their capsules.  I went over the possible side-effects of the drug with her.  She wanted to give it a try.  So I prescribed  zafirlukast 20 mg twice daily for 3 months.  She responded with softening of her capsule.  After 3 months she asked for a refill to try to achieve more softening.  She now had a Grade II-III capsular contracture.  I agreed.  It softened to a Grade II and she was happy.  

I now have another patient who is in the same state.  I have decided to try to review the literature and see if the early study has been confirmed.  The first six articles referenced below are the ones I found.  All were small in number, ranging from 20-120 human patients or 40 rats. 

The last article cautions us to remember the adverse side effects which can sometimes be worse than the problem being treated.  In this case – liver injury with zafirlukast.  Dr James L. Baker, Jr in a commentary (7th article referenced below -- 3/2017 link removed as no longer active) gives this caution:

The effectiveness of Accolate and Singulair in treating
capsular contracture remains anecdotal. It is quite  possible that while acting as an antagonist against the
leukotriene receptor, Accolate and Singulair may in reality work as a histamine receptor site antagonist and cause the relaxation of the myofibroblast, with improvement in capsular contracture in some patients. However, the increasing evidence of an association between treatment with Accolate and liver dysfunction in patients with asthma, as reported by Dr. Gryskiewicz, is a powerful argument against widespread off-label use of asthma medications to treat capsular contracture without further investigation. In addition to liver toxicity, Churg-Strauss syndrome (systemic eosinophilic vasculitis) has been reported with both drugs, more frequently with Singulair. This syndrome can have permanent ramifications, including limitation of lifestyle.

Surgeons treating patients for benign conditions with
medications carrying potentially lethal side effects should thoroughly advise patients of the off-label status and the serious risks. I discourage the use of Accolate and Singulair in the treatment of capsular contracture until such time as we can prove through laboratory research exactly how these drugs work on the myofibroblast and capsular tissue and better determine the risk-reward ratio of the therapy.

The six articles which looked at the effectiveness of zafirlukast for treating capsular contracture while noting the positive response in many of their patients also note that further studies need to be done.

Conclusions

Zafirlukast appears effective in treating early capsular contracture after primary submuscular breast augmentation using saline-filled, smooth-walled implants. Further prospective studies with control groups and long-term follow-up will be needed to address many unanswered questions, including whether leukotriene inhibitors have long-term effects on capsular contracture following breast augmentation.

If this patient and I decide to proceed with zafirlukast treatment, I will be sure she is aware of the potential side effects (minor and major) of the drug.


REFERENCES

1.  A new treatment for capsular contracture. (Letter to the editor);  Aesthetic Surg. J. 2002; 21: 164-165; Schlesinger SL and Heck RT.

2.  Zafirlukast (Accolate): A new  treatment for capsular contracture;  Aesthetic Surg. J. 2002; 22: 329-336; Sclesinger SL, Ellenbogen R, Desvigne MN, Svehlak S, and Heck R. 

3. The effect of zafirlukast (Accolate) on early capsular contracture in the primary augmentation patient: A pilot study; Aesthetic Surgery Journal, Volume 25, Issue 1, Pages 26-30 (January 2005); R.Reid, S.Greve, L.Casas

4.  The Effects of Zafirlukast on Capsular Contracture: Preliminary Report;  Aesthetic Plastic Surgery, Volume 30, Number 5, October 2006 , pp. 513-520(8); Scuderi, Nicolò; Mazzocchi, Marco; Fioramonti, Paolo; Bistoni, Giovanni

5.  Effects of zafirlukast on capsular contracture: controlled study measuring the mammary compliance; Int J Immunopathol Pharmacol 2007 Jul-Sep; 20(3):577-85; Scuderi N, Mazzocchi M, Rubino C

6.  Reduction of Capsular Thickness around Silicone Breast Implants by Zafirlukast in Rats; Eur Surg Res 2008;41:8-14 (DOI: 10.1159/000121501); A. Spano, B. Palmieri, T. Palmizi Taidelli, M.B. Nava

7.  Investigation of accolate and singulair for treatment of capsular contracture yields safety concerns;  Aesthet Surg J. 2003 Mar;23(2):98-101; Gryskiewicz JM

Macrodactyly

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. 

Macrodactyly is an uncommon anomaly of the extremities.  It can affect both the fingers or toes which become abm=normally large due to overgrowth of the tissues composing the digit.  All the tissues are involved:   bone and soft tissue-particularly the nerves, fat and skin.

Other names used for macrodactyly include megalodactyly, overgrowth, gigantism, localized hypertrophy, or macrodactylia fibrolipomatosis.

Hands are more commonly involved than feet. Most of the time (~90%) patients present with unilateral (one side affected) macrodactyly.  Often more than one digit is involved.   The most frequently involved digits of the hand are the index finger, followed by the long finger, thumb, ring, and little fingers.  Syndactyly may be present in 10% of patients.   Men are more often affected than women.

It is not known why macrodactyly occurs.  It does not appear to be an inherited anomaly, but there are some syndromes (ie Proteus Syndrome, Maffuci syndrome, and tuberous sclerosis) which may be associated with enlarged digits. There are some surgeons who believe that macrodactyly is a variant of neurofibromatosis. 

Macrodactyly may be either static or progressive.   The progressive type is more common than the static.

• In static the enlarged digit (finger or toe) is present at birth and continues to grow at the same rate as the normal digits of the hand.  The involved digits are generally about 1.5  times the normal length and width of the normal digits.
• In progressive the affected digits begin to grow soon after birth and continue growing faster than the rest of the hand.  The involved digit or digits can become enormous.

There is no medical treatment for this disorder.  It is treated by surgery.   In the hand, the indications for surgery can often be cosmetic in nature as the hand can functionally tolerate a digit with some increased width and length.  In the foot, the enlarged digit can make shoe fitting/wearing difficult.

Surgical treatment of macrodactyly is complex as multiple tissue layers are involved.  It typically will involve debulking, epiphyseal arrest, and shortening.  Multiple surgeries are the norm.

Soft tissue debulking:

• This is done to help correct the width of the digit. This is often done at the same time as the epiphyseal arrest.   The affected fingers are approached volarly with Bruner-type incisions/flaps. The fat is removed from the skin and the tissues are debulked.
• Care is taken to preserve the ulnar and radial digital neurovascular bundles. Sometimes the enlarged nerve branches will need to be sacrificed along with the enlarged subcutaneous tissues.
• When a sufficient amount of tissue has been removed, the skin flaps are overlapped and excised, which allows for tension-free closure.  It needed, skin grafts using healthy skin will be done.
• Debulking is often need to be done in staged procedures.

Shortening procedures:

• This is done to help correct the length of the digit.  Shortening procedures usually involve either surgical excision (removal) of one of the phalanges of the finger or toe, or removal of a metacarpal (hand bone) or metatarsal (foot bone).  
• Barsky and Tsuge originally introduced the two most described methods. Barsky’s technique involves removing the distal portion of the middle phalanx and proximal portion of the distal phalanx, thereby reducing the length of the finger while preserving the nail. Tsuge’s technique also preserves the nail by overlapping the dorsal portion of the distal phalanx with the volar portion of the middle phalanx.

Ray resection:

• This may be done in progressive macrodactyly.  It involved the complete removal of the digit or digits.  It is also an option if there is excessive widening of the forefoot, where digital shortening and debulking procedure may not be effective.

Epiphyseal Arrest:

• The timing of the this surgery is critical.  An attempt to “guess” the adult finger length is done by comparing the child’s digits with those of his/her parents.  When growth of the affected digits matches those of the parent, epiphyseal arrest can be performed.   This in effect will stop the bone growth of the digit.
• The epiphyses of the proximal and distal phalanges  are the ones treated by disruption or removal.   The middle phalanx epiphyses is not treated to help preserve motion at the proximal interphalangeal joint.

Other surgical options include amputation and wedge osteotomies.  Amputation is reserved for patients with nonfunctioning digits or digits that are extremely difficult to correct.  Wedge osteotomies are performed in patients who have digits that are grossly deviated.

Complications of macrodactyly surgery include poor healing of flaps secondary to devascularization or undue tension, nerve injury or decreased sensation, infection, stiffness, bony nonunion or malunion, and failure of the epiphysiodesis.

REFERENCES

Wood VE. Macrodactyly. In: Green DP, Hotchkiss RN, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingston; 1998:533-544.

Treatment of macrodactyly;  Plast Reconstr Surg. 1967; 39:590-599; Tsuge K.

Congenital anomalies of the hand; Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. New York, NY: Little, Brown and Company; 1994; Upton J, Hergrueter C.

Macrodactyly; Boston Children’s Hospital website

Macrodactyly; Wheeless’ Textbook of Orthopaedics

Shout Outs

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

Pharmamotion is this week's host of Grand Rounds. You can read it here.  It comes to us from Argentina!  Check it out:

I’m starting this Grand Rounds with a confession: I completely suffered of lack of time for this Round’s preparation. Maybe you are wondering why, since this blog carnival is perfectly scheduled. Well, the thing is that here in Argentina winter has arrived and things are starting to get a bit more complicated than we thought. I think that most of you guessed what I am talking about. Yes! The current pandemic of Influenza A(H1N1) has settled in South America and I was hired to cover night shifts in a local hospital

#1 Dinosaur comes out of anonymity as she announces the publishing of her first book!  Congratulations!

Question: What do anonymity and virginity have in common?
Answer: You can only lose them once, so make it count.
I am pleased, proud and thrilled to announce the upcoming release of my first book. From Kaplan Publishing, on August 4, 2009:

GrrlScientist is trying to win a trip to Antarctica!    She needs your help.  Here’s how:

I've posted a picture and written a 300 word essay (which I will no doubt revise over time) and my entry is now public. Voting ends on 30 September 2009, and the Official Quark Blogger will travel to Antarctica in February 2010 to blog about the experience, chronicling the action, the emotion, and the drama as their polar adventure unfolds.

My official essay where you can vote for me.

Dr Rob is now doing podcast as the “House Call Doctor”  giving “quick and dirty tips” to help you take charge of your health.   You can find the list of his podcasts here.  Enjoy!

Addicted to Medblogs’ calendar continues.  Dr June is … Whitecoat!  I agree with the answer he gave on this question, but go read the rest of the interview.  Oh, yeah, listen to his singing.

12. If you could be reincarnated, what would you like to come back as?
A dog with a really cool owner whose back porch backed up to a beach.

H/T to A Respository for Bottled Monsters

In one of those strange, how-did-I-get-here moments on the internet, I came across the abcnews website that shows some oddball x-rays. As they say, Viewer Discretion is Advised.

H/T to MedGadget for the link Theories of Mind Art Gallery...  The work is absolutely amazing!  It is from a Tel Aviv University physics professor named Eshel Ben Jacob.  Here’s one used in the MedGadget post.

The International Quilt Study Center &Museum shows off one of the amazing quilts from our collection each month in their “quilt of the month” section.  This month the quilt is one created by Gail Belmont, Cathy Morris, and Marie Aquino for the Quilts of Valor Foundation.

 

This week Dr Anonymous will be taking July off. You might want to use this time to listen to some of the shows in his Archives.

Preventing and Treating Skin Tears

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. 

If you work with elderly patients, then you have probably seen “skin tears.”  There is a nice basic article (see full reference below) on the topic that recently crossed my desk.  I’d like to share some of the information with you. (photo credit)

In considering the mechanism of skin tears, I love the way Dr Salcido (2nd reference below) puts it.  His paper explanation could be useful in explaining the problem to patients.

I will consider the etiologic factors associated with the development of skin tears through these 2 subdivisions:  pathomechanical & pathophysiological.

The French term la melodie de la peau de papier ("the melody of the little piece of paper") is useful to describe both the mechanical (human machine interface) and the pathophysiological (human) mechanisms of skin tears.

To make the point, try the following experiment. First, take a clean smooth piece of paper on a flat surface and run your hand and fingers over the top surface. There should be no drag or friction, and the surface tension should be minimal-a smooth ride, if you will.

Now take that same paper, fold it, make a tear in it, and, finally, wrinkle and moisten it. Now repeat the experiment by the hand motion. There is a significant increase in the drag coefficient (Cd) (increasing the resistance and shear forces), decreased surface tension, and further damage to the paper surface. In this experiment, the paper was the surrogate for the skin, and I consider this a model for explaining the mechanisms of mechanical forces and how they contribute to skin tears.

The main article has a nice list of risk factors for “skin tears” that should be considered when dealing with patients:

• Advanced age (>85 years of age)
• Sex (female)
• Race (white)
• Immobility (chair or bed bound)
• Inadequate nutritional intake
• Long-term corticosteroid use
• History of previous skin tears; presence of ecchymoses
• Altered sensory status or cognitive impairment
• Stiffness and spasticity
• Using assistive devices; Visual impairment
• Applying and removing stockings
• History of vascular, cardiac, and/or pulmonary problems

Many of the prevention strategies shared are common sense and focus on fall prevention – ie adequate lighting, removing clutter from a pathway, avoiding scatter rugs, making the bathroom safe for bathing.  Other strategies focus on removing sources of skin trauma – ie padding edges of furniture and equipment, avoiding adhesive products on frail skin, keeping fingernails and toenails cut short. 

Lift patients, do not drag them across sheets or surfaces.  Reduce moisture from incontinence or other sources.

Improved nutrition and hydration are important in prevention, as well as being gentle with the skin.

Once a skin tear has occurred, the same principles used to manage other wounds should be used.    First, the wound has to be assessed.  They suggest using the Payne-Martin classification of the skin tear.   However, the STAR consensus does not

Once again, the STAR consensus was to simplify the parameters of assessment and

a category 1a or 1b skin tear is one ‘where the edges can be realigned to the normal anatomical position
(without undue stretching)’.

A category 2a or 2b skin tear presents ‘where the edges cannot be realigned to the normal anatomical position (without undue stretching)’.

Whichever classification you use, remember these are acute wounds and have the potential to close by primary intention.

 Next,  the wound has to be cleaned -- removing bacteria and necrotic tissue.  When thinking about repair, it is usually best to avoid staples and sutures as the fragile tissue won’t hold.  So go straight to the next step – the dressing.

Most skin tears tend to achieve wound closure within 7 to 10 days using the following treatment plan:

• Category 1a or b skin tears can be treated with adhesive strips anchor or Dermabond to the re-approximated edges
• Category 2a or b skin tears can be treated with soft silicone or low tact foam dressing. 

All can be treated by using a  transparent film dressing (ie POLYSKIN* II) if there is minimal moisture.  The longer the dressing can be left unchanged, the better for the fragile skin.  It will often need changed every 3-7 days, but if the wound looks fine underneath consider leaving it another day or so.  If fluid develops under the transparent film dressing, then it will need to be changed promptly.

REFERENCES

Prevention and Management of Skin Tears; Advances in Skin & Wound Care, 22 (7):  325-332, July 2009; LeBlanc, Kim BScN, RN, ET, MN; Baranoski, Sharon MSN, RN, CWOCN, APN, DAPWCA, FAAN

Deconstructing Skin Tears; Advances in Skin & Wound Care,  22(7):294-295,July2009;  Salcido, Richard MD

STAR: a consensus for skin tear classification; Primary Intention Vol. 15 N o. 1 FEBRUARY 2007; Carville K, Lewin G, Newall N, Haslehurst P, Michael R, Santamaria N & Roberts P

SurgeXperience 301 – 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 host for  SurgeXperience 301 (July 12th) will be  Buckeye Surgeon.  This is the beginning of the 3rd season!

The deadline for submissions is midnight on Friday, July 10th.  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.   If you would like to be the host in the future, please contact Jeffrey who runs the show here (3/2017--link no longer active).

Lou Gehrig's Speech 70 Years Later

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

This is the 70th anniversary of Lou Gehrig’s famous farewell speech (http://baseballhall.org/discover/lou-gehrig-luckiest-man).   It is still very inspiring.

For more information on ALS (Amyotrophic Lateral Sclerosis):
Lou Gehrig:  the Official Website
ALS Association
National Institute of Neurological Disorders and Stroke

Patriotic Sampler Quilt

One thing my blog has helped me do is better documentation of my quilts.  My husband has been after me for years to take better pictures of them before giving them away.  He wanted me to keep records of the each one.  Unfortunately, I didn’t do a good job of that in the past.  I found two Polaroid photos of this patriotic sampler quilt that I made after September 11, 2001.  I quickly took the photos before mailing it in the spring of 2003 to Laura and George W Bush.  

Anyway, I had the four churn dash blocks and the small pinwheel and pineapple blocks as my start.  If my memory is correct the blocks are 12 in square.  I think the sashing is 3 in wide.  I think the borders are 5 inches wide.  If my memory is correct, then the quilt measures 52 in X 67 in.

I’m not sure if I have the names of all the blocks correct, so feel free to correct me if not (Celeste).  Starting at the top from left to right, then the second row from left to right, and so on:

1.   Evening Star with Pinwheel in center
2.   Churn Dash
3.   Stepping Stones
4.   Odd Fellow’s Cross
5.   Grecian Cross (rotated 45 degrees)
6.   Many Pointed Star
7.   Churn Dash
8.   Ribbons
9.   Churn Dash
10.  Eight-pointed  Star with Pineapple Square in center
11.  Churn Dash
12.  Mosaic Star

I added several rosettes which you can see (though not well – I wish I’d taken better pictures.).  The one with the gold base began as a strip of black & white striped ribbon folded into the rosette.  The small black one on the “ribbons” block is a rushed rose.

The fabric on the left side border has frogs holding American Flags which I just loved but didn’t have enough of to do all four borders.  It is on two borders.  The other two have red fabric with roses.

Don’t Forget HIPAA Privacy Rules

 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 we move towards EMR’s, the ability to know who has looked at the medical record may get more and more in trouble. While we are all curious about our friends, neighbors, and celebrities (local or global), it is important to respect each others privacy. This local Arkansas story (3/2017-- link no longer active) shows the importance of this respect.

Hospital emergency room coordinator Candida Griffin, patient account representative Sarah Elizabeth Miller and Dr. Jay Holland, a family doctor who worked part time at the hospital, each face up to a year in prison and $50,000 fine if convicted of the misdemeanor charge.

I would hope that all three of the people listed above would have “known better.” When this story broke earlier this week, the staff in the OR and I had a nice discussion on who gets HIPAA training and how much each get.

I think as part of their punishment, they and perhaps the facility (St Vincent Health System) should have to do refresher courses on HIPAA privacy rules.

The hospital said in November that it fired up to six people for looking at Pressly's records after a routine patient-privacy audit showed that as many as eight people gained access to them.

It was not immediately clear whether others fired from the hospital would face charges. U.S. Attorney Jane Duke declined to comment about the charges Tuesday.

With paper charts, there isn’t a trail proving you or I accessed the chart without need to do so. With EMR’s there is but this trail is not fool-proof. If I haven’t logged off and you look over my shoulder, then ….

If you haven’t logged off and I ask for a quick look at patient 007’s lab work and you do me a “favor” of checking quickly. See, not perfect. No harm was intended and patient 007’s info may never be “leaked” to the press, but someone who perhaps had no need to access it did so.

My circulating nurse in the OR during the discussion revealed that she had heard a lot of talk about the Ann Pressley case which she admits she should not have. She didn’t access the chart. She was working in another hospital’s ER. It was the police and EMT’s doing the talking. There is no trail to “prove” those violations of patient privacy trust.

We need to be more careful in discussing patients and cases. We still need to be able to discuss difficult or unusual cases, but this can be done without breaking a patient’s trust or privacy. Names and identifiers don’t have to be used when stumped by a rash or odd presentation.

Dr Holland had no malicious intent, just curiosity. Be careful.

Arkansas Democrat Gazette article Doctor, ex-hospital employees charged over Pressly records (subscription required) written by Linda Satter

3 charged with getting TV anchor's medical records by Jon Gambrell (no subscription required)

Fireworks Safety

Time for a reminder of safe firework use.  I hope you will all have a safe and happy July 4th.  Be safe and stay out of the ER. 

Please use the following tips:

• Never allow children to play with or ignite fireworks.
• Read and follow all warnings and instructions.
• Fireworks should be unpacked from any paper packing out-of-doors and away from any open flames.
• Be sure other people are out-of-range before lighting fireworks. Small children should be kept a safe distance from the fireworks; older children that use fireworks need to be carefully supervised.
• Do not smoke when handling any type of "live" firecracker, rocket, or aerial display.
• Keep all fireworks away from any flammable liquids, dry grassy areas, or open bonfires.
• Keep a bucket of water or working garden hose nearby in case of a malfunction or fire.
• Take note of any sudden wind change that could cause sparks or debris to fall on a car, house, or person.
• Never attempt to pick up and relight a "fizzled" firework device that has failed to light or "go off"
• Do not use any aluminum or metal soda/beer can or glass bottle to stage or hold fireworks before lighting.
• Do not use any tightly closed container for these lighted devices to add to the exploding effect or to increase noise.
• Never attempt to make your own exploding device from raw gunpowder or similar flammable substance. The results are too unpredictable.
• Never use mail-order fireworks kits. These do-it-yourself kits are simply unsafe.

Infections After Face Lifts

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

When you read articles at sites like MedScape or MedPage Today, you are often referred to other articles of interest.  That’s how I came across this one on the MedPage Today site.   I went there to read the one on “Sinus Infections Cause Toxic Shock Syndrome in Children”.  Both are interesting articles, but I want to discuss the article referenced below that was discussed on MedPage Today.

The topic is postoperative infections in face lift surgery.  The stated objective of the article:

To determine the incidence of methicillin-resistant Staphylococcus aureus (MRSA)-positive surgical site infections after face-lift surgery and to discuss the screening, prevention, and treatment of such infections.

MRSA infections are never a good thing, but as a postoperative face lift infection – really not a good thing.

The article mentions having done a literature review and finding only one published article (second reference below) on the incidence of postoperative surgical site infections (SSIs) after rhytidectomy.  It was a retrospective study performed more than 10 years ago on 6166 consecutive face-lifts.   In that study only 11 infections requiring hospitalization were found (0.18%) and none of the cultures were positive for MRSA.  

This current article is also a retrospective study.   Charts of 780 patients from January 2001 to January 2007 were reviewed.  These patients all had a deep-plane rhytidectomy.  Some had other procedures such as blepharoplasty, browpexy, rhinoplasty, autologous fat transfer, laser resurfacing, and chemical peel. All were done as outpatients.

The article highlights the techniques used for infection prevention:

The morning of surgery, all patients showered and washed their hair with chlorhexidine solution.

After the induction of anesthesia and before incision, the patients' faces were scrubbed with chlorhexidine and povidone-iodine.  Attention was placed along the areas of the face-lift incision, including the hair-bearing scalp 5 cm posterior to the hairline.

Sterile towels were then secured around the patient's head to sterilely secure the surgical site.

Before incision, 1 g of intravenous cefazolin sodium (Ancef) was administered (clindamycin if the patient was allergic to penicillin).

After surgery, all patients were given a 7-day prescription for oral cefadroxil (Duricef).

The patients were then seen on postoperative days 1, 5, 8 (suture removal), 21, and 40. During each visit, they were examined for any signs of infection, such as erythema and fluid collection.

There were 4 patients (out of 780) who developed postoperative wound infections with cultures that were positive for MRSA.  Another patient developed a wound infection that yielded anaerobic skin flora.  This gave an overall infection rate was 0.6%.   As noted in the article 80% (4/5) of the infections were MRSA related.

The article highlights each of the five patients with individual case reviews.  I want to highlight the outcomes in terms of scarring.  With the exception of the first case, there is really not enough follow up on the scar evaluation.

Case 1:  “Six months after surgery, the scarring was barely perceptible.”

Case 2:  “Four weeks after surgery, the patient had healed completely. She had no scarring, and the area of the incision that was opened had healed well.”

Case 3:  “and the patient healed uneventfully over the next 7 days.”

Case 4:   “The patient healed rapidly, and she had no evidence of infection or scarring after 7 days of treatment.”

Case 5 (non-MRSA):   “She improved rapidly and healed well”

The article makes some nice points for setting up screening protocols.  For the facelift patients, perhaps preoperative cultures of the nose and throat.

Those cases with MRSA colonization and no clinical infection were treated with mupirocin (Bactroban) nasal ointment 3 times daily and 2% triclosan (Aquasept) washes twice daily for 5 days.

Povidone-iodine (Betadine) mouthwash was also used 2 to 3 times daily as gargle for 5 days. Chlorhexidine mouthwash was used in patients with a contraindication to iodine.

The article does a very nice job of point out the importance of postoperative surveillance, aggressive early treatment (incision and drainage, culture, antibiotics).

Once MRSA infection is diagnosed after a face-lift, aggressive treatment is advised to prevent rapid progression of the infection. Prompt initiation of appropriate antibiotic therapy, along with incision and drainage, is essential. The cosmetic nature of rhytidectomy may make facial plastic surgeons hesitant to open wounds that have an infected collection. However, openly draining wounds that have collected MRSA-positive material is prudent.

…….

The facial plastic surgeon must be quick to culture any suspicious fluid or discharge. The result of the sensitivity and resistance profile from these cultures will be the ultimate guide for the antibiotic regimen. Prompt culture cannot be stressed enough. The infection can spread rapidly along the surgical dissection site and become extensive in a very brief time frame. …….

REFERENCES
"Methicillin-resistant staphylococcus aureus-positive surgical site infections in face-lift surgery" Arch Facial Plast Surg 2008; 10: 116 – 123; Zoumalan RA, Rosenberg DB

Infections requiring hospital readmission following face lift surgery: incidence, treatment, and sequelae;  Plast Reconstr Surg. 1994;93(3):533-536; LeRoy JL Jr, Rees TD, Nolan WB III.