SurgeXperiences -- 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Updated 3/2017 -- all links (except to my own posts) removed as many no longer active.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.

SurgeXperiences is a blog carnival about surgical blogs that occurs every two weeks. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.  

The last edition (319) was hosted by Vijay, Scan Man’s Notes, three weeks ago.  You can read it here.   Jeffrey has listed my Easter Sunday Update as edition 320.

I will be the host of this next edition (321), so please get those submissions in.   The host of the next edition (321) has not been announced, but don’t let that keep you from making your submissions.  It is scheduled to occur on April 18th.   Be sure to make your submissions by the deadline: midnight on Friday, April 16th.   Be sure to submit your post via this form.

 

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

Her Scar’s Story

“Can you remove this scar?”

“No, only change it.” She looks deflated. I ask “What happened?”

“My ex-husband stabbed me,” she quietly says.

“I’m sorry. I can’t remove the scar or it’s history. We’ll give it a new story.”

“How?’’

“A new scar. Let it’s story begin there.”

She smiles.

Victorian Wheeling Spools Quilt

I began this quilt in the fall of 2008.  I actually finished piecing it nearly a year ago, but until a few months ago had not decided how I wanted to quilt it.  I found two quilting stencils that worked wonderfully. 

The fabric for this quilt was purchased in the 1990s.  It is from a collection of 33 different fabrics called “Victorian Wheeling” which was designed by Jennifer Simpson. I bought a set that included a fat quarter of each fabric. The fabric was then put away until I decided how I wanted to use it:  the spool block.  It combines my sewing (the spool of thread) and does a nice job of showing off the fabrics.

The quilt is machine pieced and quilted.  Each block is 6 in square, but the finished quilt measures 41.5 in due to some slight shrinkage with the quilting.

It is difficult to see the quilting on the black, but on the squares you can see it.   Here are a few close shots so you can appreciate the lovely fabrics.

Lipodissolve “Too Good to be True”

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

I have long been skeptical of Lipodissolve claims.  Patients would ask about the injections that dissolve the fat without surgery.  How it worked?  How safe is it?  Do you do it?  Do you know anyone who does?

The FDA has finally issued a warning

On April 7, 2010, FDA announced it had sent warning letters to six medical spas in the United States—and a cyber letter to a company in Brazil—for making false or misleading statements on their Web sites about drugs used in the procedure, or for otherwise misbranding lipodissolve products.

The U.S. medical spas receiving warning letters make various unsupported claims about lipodissolve, such as assertions that the products used in lipodissolve

• are safe and effective
• have an outstanding safety record
• are superior to other fat-loss procedures, including liposuction

Notice the “unsupported claims” phrase.  I have never been able to find any good articles regarding lipodissolve so that I could intelligently answer questions regarding it. 

Lipodissolve is a procedure where the patient receives a series of drug injections intended to dissolve and permanently remove small pockets of fat from various parts of the body.   This procedure is also known as injection lipolysis, lipozap, lipotherapy, and mesotherapy.

The drugs most regularly used in the lipodissolve injection procedures are phosphatidylcholine and deoxycholate (commonly called PC and DC, respectively).  Other ingredients may also be used, including drugs or components of other products such as vitamins, minerals, and herbal extracts.

None of the drugs or products used have been approved by the FDA for fat dissolving or fat removal.

The FDA wants any potential lipodissolve patients to be aware:

• None of the drugs/products used in the procedure have been evaluated or approved by the FDA.
• The FDA is not aware of evidence supporting the effectiveness of the substances used in lipodissolve for fat elimination.
• The safety of the substances used in lipodissolve, when used alone or in combination, is unknown.
• The FDA is not aware of clinical studies to support medical uses of lipodissolve.

In addition, FDA has reports of unexpected side effects in people who’ve undergone the lipodissolve procedure.  These side effects include:

• permanent scarring
• skin deformation

deep, painful knots under the skin in areas where the lipodissolve treatments were injected

I continue to tell patients that I do not advise the use of these lipodissolve procedures.   For me (and the FDA), lipodissolve is “too good to be true.”

Evidence (or Lack Thereof) Behind Retinoids

Many over-the-counter (OTC) cosmetic products contain retinoids and are promoted (advertised) as anti-aging products.  This article (first reference below) in the February issue of the Aesthetic Surgery Journal is a review of the evidence behind retinoids in cosmeceutical products.  It turns out there isn’t much.

First, let’s begin with some definitions:

Retinoids include Vitamin A and its derivatives which may be either natural or synthetic.

Cosmeceutical products are formulations which are not classified as prescription medications. 

Retinoids which are prescription medications include tretinoin, isotretinoin, alitretinoin, tazarotene, and adapalene.  Because they are classified as prescription medications, these do not qualify as cosmeceuticals.

This is an important distinction as there is a large body of evidence to support tretinoin in the treatment of photoaging.  This article focused on the cosmeceutical retinoids.

The article looks at retinyl-acetate and retinyl-palmitate, both vitamin A ester derivatives; retinol, a precursor to retinaldehyde and retinoic acid; and topical retinaldehyde.

The authors conclusions:

There is a substantial amount of evidence supporting the efficacy of tretinoin in the treatment of photoaging. The evidence supporting retinoid-based cosmeceuticals, however, remains sparse. There are a number of in vitro studies, with a smaller number of in vivo studies. Based on the hierarchical levels of evidence (with well-designed, randomized, controlled trials providing the highest level), retinaldehyde appears to be the only retinoid-based cosmeceutical to be effective in the treatment of photoaging. A large, randomized, controlled trial assessing retinyl propionate concluded that it had no significant effect on photoaging. There is evidence from a small, randomized, controlled trial showing that retinol has effects on human skin and supporting its potential as an agent against photoaging.

However, large-scale clinical studies would need to be undertaken to investigate this further. Therefore, we conclude that products containing retinyl-acetate or retinyl-palmitate are unlikely to have a significant beneficial effect, but retinaldehyde-containing cosmeceuticals have evidentiary support for their benefits in patients with aging skin. Retinol has potential benefit, but more research is needed.

 

 

 

 

REFERENCE

Cosmeceuticals:  The Evidence Behind the Retinoids; Aesth Surg Journ Vol 30, No 1, February 2010; Babamiri, Kajal MD, Nassab, Reza MBChB

Clinical Review: Topical Retinoids; Medscape article, December 2003; Sheri L. Rolewski

Retinoids: Progress in Research and Clinical Applications; Plastic and Reconstructive Surgery. 98(1):180, July 1996; Ship, Arthur G.

Treatment of Photodamaged Skin with Topical Tretinoin: An Update; Plastic and Reconstructive Surgery. 102(5):1672-1675, October 1998; Heffel, Dominic F.; Miller, Timothy A.

Cosmetic Dermatology: Principles and Practice; Plastic and Reconstructive Surgery. 113(3):1064-1065, March 2004; Chavis, Dion D.

Insurance Premium Increase

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

Physicians aren’t exempt from the struggles with personal health insurance coverage, affordability, denied coverage, etc.   When I finished my training and opened my practice 20 years ago I had to buy individual coverage.   All options included a rider that excluded coverage on my uterus and ovaries due to fibroid surgery during training.  So when I had my TAH & BSO a few years later, the entire cost came out of my pocket.  Fortunately, I knew how to ask for cost reductions, but still…

My husband and I are both small business individuals.   I have always carried our health insurance under my name (office).  Over the years we have gone to a health savings account with a high deductible to keep the cost reasonable.  Fortunately, we have been mostly healthy.

Last month, we received a letter from Assurant Health telling us of a policy change that includes a $75 ER visit charge.  I thought this might be their way of avoiding a policy increase, but no.  Last week I received the notice regarding an increase to our policy.  Currently, our premium is $619.76 per month plus a mandatory $100 deposit into the HSA each month. 

The notice included the “good news”  -- “Congratulation!  You’re a Healthy Discount candidate.”  To determine your eligibility for the Healthy Discount, follow these simply instructions:  1.  Answer all six questions below.  Please consider the last 12 month when answering these questions……”

• Been recommended or scheduled for surgery that has not been complete?
• Been recommended to have or is anyone contemplating infertility treatment or been treated for infertility?
• Received or been recommended to have any treatment for alcoholism, alcohol or drug abuse or addiction or mental or nervous conditions?
• Been cited for operating a moving vehicle under the influence of alcohol or drugs?
• Received a diagnosis for any serious medical condition such as heart disease, stroke, cancer, diabetes, HIV, AIDS, or any other progressive disabling condition?
• Been incapacitated or hospitalized due to an accident or illness?

The “good news” is that since we can answer no to all six of those questions, our new premium will be $761.71 per month rather than $842.87 per month.  The mandatory $100 deposit into our HSA remains the same.
A simple 23% increase rather than a 36% increase. 

Earlier this year policy increases of up to 39% in California, Indiana, etc led The House Committee on Energy and Commerce to summon the chiefs of WellPoint, UnitedHealth Group, Humana and Aetna to the Hill to answer questions.  Policy increases by other companies seem to be flying under the radar.

If you missed them, check out the posts by Shadowfax here and here on Assurant Health.

Shout Outs

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

Today, April 6th, is World Physical Activity Day.  I didn’t know this before reading @DrVes’s tweet last week:  Run for your life - April 6 is World Physical Activity Day http://goo.gl/NshG

This fits right into the theme for this week’s Grand Rounds chosen by the host Dave Munger, The Daily Monthly --  Fitness and Nutrition.   You can read this week’s edition here.

Welcome to the Grand Rounds — a weekly roundup of medical and health blogging, hosted on a different blog each week. This edition is volume 6, number 28 (click here for last week’s edition).

Since this is fitness month on Daily Monthly, I asked this week’s participants to focus on nutrition and fitness where possible, and we got a great response.

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Dr. Dean, The Millionaire Nurse Blog,  is the host of the latest edition of Change of Shift (Vol 4, No 19) !   It is the April’s Fool Edition.  You can find the schedule and the COS archives at Emergiblog. (photo credit)

Kim at Emergiblog, asked me to host Vol 4, number 19 edition of Change of Shift.  On April Fool’s Day!!!

April Fool!!!!!

And for you non-nursing readers, Change of Shift is a nursing blog carnival. …….
In Honor of April Fools Day, I thought I would share quotations that use the word “Fool.”  See if you recognize any of them.

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Dr Howard Luks, The Orthopedic Posterous, gives us an interesting post:  Health Law Does Little to Curb Overuse of Care: nyt #hcr #hcsm.   The comments are an important part of this discussion.

Docs... we can step up and control costs... limiting expenses to provide a better world for our children should be all the incentive you need!

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I was pointed to this NYTimes article by @purplesque and @ctsinclair:  Helping Patients Face Death, She Fought to Live.

By the time she was 38, Dr. Desiree Pardi had become a leading practitioner in palliative care, one of the fastest-growing fields in medicine, counseling terminally ill patients on their choices.

She preached the gentle gospel of her profession, persuading patients to confront their illnesses and get their affairs in order and, above all, ensuring that their last weeks were not spent in unbearable pain. She was convinced that her own experience as a cancer survivor — the disease was first diagnosed when she was 31 — made her perfect for the job. ………….

And here’s Paul Levy’s comments on the article:  Should we let the death issue die?

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Yesterday, I caught part of the Diane Rhems show “Savior Siblings”  discussing “the medical and ethical issues of using in vitro fertilization with genetic testing to produce a baby who could be a genetic match to save the life of a sibling with a fatal illness.” 

Guests

Beth Whitehouse -- reporter for Newsday and adjunct professor of journalism at Columbia University's Graduate School of Journalism, author of the book, "The Match:"Savior Siblings" and One Family's Battle to Heal Their Daughter.

Laurie Strongin  -- founder and executive director of the Hope for Henry Foundation, author of "Saving Henry: A Mother's Journey"

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I have @sandnsurf to thank for tweeting this:  RT @velopilot Fibonacci numbers visualized. http://vimeo.com/9953368 wow, brings out my inner geek..

Nature by Numbers from Cristóbal Vila on Vimeo.

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Dr Anonymous  doesn’t seem to have a BTR show scheduled this week. 

Upcoming Dr. A Shows (9pm ET)

4/14:  Psychiatric Social Worker Brandice Schnabel
4/22: DG & Tiffany Hollums and their adoption journey

Scalp Reconstruction – an Article Review

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.

The March issue of Plastic Surgery Practice has a very nice article on scalp reconstruction (full reference below). The short article is an overview of HRS (hair restoration surgery) options for massive hair loss resulting from illness or injury.

The degree of deformity generally determines the treatment choice. Advancements in HRS in the past 2 decades are significant in yielding natural and almost undetectable results. Using a combination of HRS and cosmetic and reconstructive techniques, most deformities can be treated effectively.

There are many HRS techniques available, including follicular unit transplantation (FUT), follicular unit extraction (FUE), scalp reduction, scalp flaps, and tissue expansion.

The article gives some nice tips for use of tissue expanders:

• Planning is critical. Patient/family counseling regarding temporary deformity is crucial.
• It is best to overestimate the needed expansion and choose the largest commercially available expander that fits the patient’s anatomy.
• The vertical dimension is the most important factor providing the greatest gain in flap expansion. When the distance over the expanded tissue minus the base width of the expander is equal to 120% of the defect width, the expansion is complete.
• Overexpansion even by a modest amount will increase patient safety by providing excess tissue to cover the defect, allowing closure with minimal or no tension.
• If the entire defect cannot be removed and the residual defect is significant, leave the expander in place for a second expansion.

The article also mentions Operation Restore , a charity program which matches prospective hair loss patients with volunteer ISHRS physicians to obtain hair restoration services to help restore the physical and emotional wellness of the individual. The foundation will provide financial, travel, lodging, and medical assistance to eligible patients. The ISHRS Pro Bono Program was also featured in Association Forum Magazine.

Other posts you may find interesting:
Scalp Avulsion Injuries
Eyebrow Reconstruction
Hair Transplantation

REFERENCE

Scalp Reconstruction: An Aesthetic Challenge; Plastic Surgery Practice, March 2010, pp 14-18; E. Antonio Mangubat, MD

Reconstruction of Acquired Scalp Defects: An Algorithmic Approach; Plastic & Reconstr Surg, Vol 116(4):54e-72e, September 15, 2005. Leedy, Jason E. M.D.; Janis, Jeffrey E. M.D.; Rohrich, Rod J. M.D.

Happy Easter Sunday

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.

First, I’d like to wish you all a Happy Easter.  I’ll begin mine with the Community Easter Sunrise Service down at the Arkansas River front. 

Next, I’d like to say I’m not sure what happened with #320 edition of SurgeXperiences which was due today, so I’ll just give you a few links to some surgical blog posts.

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

 

• A classic op-ed post over at KevinMD’s by surgeon Sid Schwab:  "No more and no less a human being than my patients"
• Dr. Bruce Campbell, Reflections in a Head Mirror, gives us this very thoughtful post:  Turning Away.
• Bongi, other things amanzi, gives us a story relating how six degrees of separation can change how patients get treated.  He has another on anatomy.
• Via TBTAM’s recommendation as I somehow missed this when it was published November 21, 2009 comes a post from MommyDoc:  And that’s the way Sue “C’s” it.
• From Aggravated DocSurg:  If they could only all be taken to Rampart Hospital
• From Michael, Medgadget comes this post:  Photo Contest Profiles Role of Science in Modern Life.  (follow the links included in the post)
  
• Kane Guthrie, Life in the Fast Lane,  gives us a lesson on Minor Injuries 001.
  
• Dr. Wes tells us about a carpenter who had his  one heart nailed and lived to tell about it.
  
•  Buckeye Surgeon gives you the answer to his weekend image.  Go check yourself.
  

 

 

Hope you enjoy your day!

Elated

Crying she says, “Dr. Bates, my right implant has deflated. Help!”

“Don’t panic. It’ll be okay.”

We review the options and risks. Fortunately, her 9 year old implants are covered by the 10 year plan.

“Dr. Bates, can I go bigger this time?”

“Yes, that’s an option.”

Smiling, “Then let’s do it.”

Wisp Scarf for Kristen

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

I made my niece Kristen a pink scarf for Christmas, but she really seemed to like mine.  So I took the left over JoJoLand Harmony wool yarn from mine and knit this scarf for her.  It is approx 10 in X 62 in.  The pattern is Wisp by Cheryl Niamath.

The Lace Ribbon pattern (the pink scarf) is free on Ravelry.

Skin Grafting in Lower Third Nasal Reconstruction

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.

Skin grafts for the lower third nasal defects should not be overlooked as an option.  The article listed below  (first one)reminds us that  skin grafts can give a better cosmetic results than a local flap in certain situations.  

The lower third of the nose is defined by its margins, which include the alar rims inferiorly, the nasolabial grooves laterally, and the alar groove, which forms the junction with the upper two-thirds of the nose.

Classically, the lower third of the nose is composed of six subunits: bilateral ala and soft triangles, the central tip, and columella. (photo credit)

The skin in this area is thick, richly populated with sebaceous glands, often stiff and difficult to rotate and form into local flaps.

Criteria given for selecting lower third nasal defects that can be acceptably treated with full-thickness grafts

include defect location; size smaller than 1 cm; and a partial-thickness defect with underlying dermis, subcutaneous tissue, or perichondrium.

Rather than increasing the small defect to a larger defect (whole subunit size), the authors achieved acceptable cosmetic results using full-thickness skin grafts to reconstruct lower third defects smaller than 1 cm in diameter.

Any defects larger than 1 cm were reconstructed more successfully with entire subunit reconstructions using more standard reconstruction techniques (local or adjacent flap techniques).  Defects that involve cartilage or deeper are by definition complex nasal defects that will require onlay cartilage grafting for satisfactory reconstruction.  These are not appropriate for skin grafting.

Donor site selection is important to try to match “like with like.”   Best choices include:

The senior author prefers preauricular and more preferably forehead skin for lower third nasal reconstruction. Forehead sites offer thicker skin, with a relatively sebaceous, oily texture, and they suffer the same degree of daily sun exposure and actinic damage as the lower third of the nose.

Other donor sites available to the reconstructive surgeon include the nasolabial fold, postauricular skin, and supraclavicular skin.

Poor donor site choices:

Postauricular donor sites suffer very little (if any) daily sun exposure and have much thinner skin than the nasal lobule. Therefore, they are prone to pigmentation changes and do not provide a good contour match for reconstructing the lower third of the nose.

Likewise, the skin of the supraclavicular region contains very few sebaceous elements and is often hyperpigmented before harvest.

 

Any distortion of the alar rim or obliteration of the nasolabial groove is exceedingly noticeable and difficult if not impossible to correct secondarily so care must be taken regardless of technique used in these area.

REFERENCE

Lower Third Nasal Reconstruction: When Is Skin Grafting an Appropriate Option?; Plast Reconstr Surg. 124(3):826-835, September 2009; McCluskey, Paul D.; Constantine, Fadi C.; Thornton, James F.

Nasal Reconstruction, Principles and Techniques: Multimedia; eMedicine article, August 28, 2008; Joseph Fata, MD

Nasal Reconstruction-Beyond Aesthetic Subunits: A 15-Year Review of 1334 Cases;  Plast Reconstr Surg. 2004;114:1405-1416; discussion 1417-1419; Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK.