Talk in the OR

 Updated 3/2017-- video and all links (except to my own posts) removed as many no longer active.

I'm going to try to give you a glimpse of what we talk about in the operating room. Let me make it clear that if you take me to a party I am the "wall flower" type. Something happens in the operating room and I engage in conversation much more so than elsewhere. I love talking to the crew (male or female). So let me give you a brief introduction:

Yesterday I had 4.5 hours of surgery (two surgeries) to do in the operating room. We won't go into what type. My crew at the outpatient surgery center included four other women, ages 42 yrs to 58 years. One has two children, 1 yr and 3 yr. One has a daughter in nursing school. One has middle school and high school children and is involve in a divorce. One has grown children and a couple of grandchildren. Me, I have my dog, nieces & nephews, and neighbor's children.

The first patient sets the stage for our early conversation. As she is falling asleep, she comments "You're playing my song. How cool!" The radio was very low, but she heard Jimmy Buffett singing MargariteVille.

So after "tucking" her in we move on to my niece and sister winning the trip from said radio station to New Zealand to see Elton John in concert. From there to music we enjoy. Singers who could sing anything and we would love it. The ones with voices that just soothe. For me Dean Martin, another agrees. For another it is Willie Nelson.

We move on to Halloween. Did anyone have many or any trick-or-treaters? None of us did. The one with small children tells us about their costumes--bumble bee (1 yr old) and "mean army man" (her 3 yr son's description of himself). She describes their outing, shows pictures on her cell phone. I tell them of my two trick-or-treaters. I only ever have two--my neighbors children (girl 6 and boy 10). She was Elvira. He was a ghoul with these wonderful fake hands with loong fingers! I mention how my neighbors allow me to make goodies (popcorn balls, candied applies, brownies--different each year) for their children. We comment on how different Halloween is from our youth.

We catch up on mutual friends. A CRNA we all know recently had a BCCA removed from her upper lip. She is big on her looks (and she is very pretty) so was depressed while healing but is in better spirits now. I ask if they knew that MG's father-in-law had pancreatic cancer in addition to his esophageal cancer. It is a second primary cancer. We talk about the family fighting that is already beginning about his estate. MG has told me that some of the siblings and their wives are rumbling about the dad's business he "gave" to MG and her husband. The truth is that MG and husband bought it from the dad. The CRNA in the room mentions that her husband's grandmother recently passed. No family squabbles there, but they have had to be careful going through the house. Apparently the grandmother, having grown up during the Depression, had a habit of putting money away in odd places (books, the odd jar, etc).

School sports get some time. The mother with teenage children comments on how serious some parents take the games. She dislikes the intensity of this and is "anti" sports. I and another couple of the women, while not condoning the parents behavior, defend sports. We had gotten a lot from playing --learned how to work as a team, to show up for games and practice, etc. This somehow leads to talking about the apparent increase in number of teachers these days who seem to get involved with their students. We all agree that for us, the female teachers that engage in the this behavior are worse than the men. We try to analyze ourselves and decide it is because we think those women should be more nourishing and so we hold them to a higher standard. (yes, we are sexist).

Food gets a great deal of time. Which restaurant is the surgery center (no internal cafeteria) ordering take-out from today? Did you remember to put your request in? Have you tried their spinach-blueberry salad? Comments are made on places we have eaten lately, good dishes we had, restaurants that we forgot about and need to revisit. One comments about a recipe she found in the local newspaper a while back--Elvis Presley Pound Cake. Tells us how good it is. Promises to make one for us and bring us the recipe. Talk about Thanksgiving food. How do you do your turkey? One has a large deep fryer and tells about deep frying turkeys, offers to do one for another of the girls. Offer accepted. Cornbread dressing or no--its split.

Comments are made about the hostage situation that happened the day before in the small town of Bee Branch, Arkansas. A man had taken his ex-wife and 4 yo daughter hostage with a knife. The situation had lasted 14 hours. He had held the knife to his DAUGHTER's neck to get his ex-wife's attention. We are all outraged and saddened. We think he must be crazy. We decide we would rather think that he is mental unhealthy rather than just mean. This leads to a discussion of the poor infrastructure of our state's (and nation's) mental healthcare.

We go back to mutual friends. Anyone seen or heard from MR since she left? Is she still liking her work over at the VA? Sure miss her. What about JS? Sent her a birthday card with phone number and e-mail, but haven't heard from her. (well, I guess I could pick up the phone and call) Someone has heard that P is unhappy. Someone comments that sometimes it's not the place, but the person.

We talk about nursing school. The daughter in school is being talked into a PhD in nursing by her instructors. I ask why one would want a PhD in nursing? What does she want to do--teach? The mother says her daughter is really good with patients, loves geriatrics. I ask if she'll be able to do patient care with a PhD or will she be told "You're over qualified."? I suggest (and I know I may be wrong here) that she might want to look into nurse practioner or physician assistant degree. I give her a name of a nurse practioner I know who I think would be willing to talk to her daughter.

We get off on cleavage and heels. I comment that I think that little "jiggle" at the top of the breast is lovely and difficult to get with implants. (If you don't know what I mean, take at look at Jennifer Love-Hewitt in the Hanes bra commercial) The woman with the 17 yr daughter comments that she thinks (for 17 yr) her daughter wants to wear her neckline too low [the old mother-daughter conflict]. We all comment on our own comfort level for neckline. I never undo more than one button on a button-down shirt. E says she goes for three. Wow! I just don't have the nerve. Heels get coverage. We all agree that they make our legs look better. We all agree that we can comfortably do 2-2.5 inch heels, but over 3 inches gets very uncomfortable to our feet. I relate to them the name for stilettos I learned from a Boston scrub nurse during my plastic surgery residency--"FMP's" One asks what that means--"F*ck Me Pumps" I reply. I tell them that I now (the prude that I am) have a hard time wearing heels that are very high without thinking about that. The things that get stuck in your head.

I try to tell them about blogs (though Dr Rob does a much better job). What is that? I tell them about a few of the ones I read--the Gyn from Manhattan (TBTAM), the radiologist from India, the scrub tech who loves trauma, the ER nurse, the general surgeon in Africa just to mention a few. The "loves trauma " makes us all review how we enjoyed it before our bodies complained so much the next day. The reference to Africa makes us remember the Pediatric cardio-thoracic surgeon we had here a few years ago who committed suicide on Christmas Day. It makes us sad, the loss, the failure of medicine to adequately treat his long history of depression.

So there is a glimpse of the conversation that we had yesterday. My husband often asks me what we talked about in the OR. I find it hard to retell. I'm not at all sure that you will get the true flavor. I enjoy being there. Somehow the mask, the place, loosens my tongue more than any drink can do. All this and the patient still gets our attention. When necessary, all talk ceases.

Travel Wallets

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

Recently my niece and my sister (her mom) won a trip from a local radio station. It's a trip to New Zealand to see Elton John in concert December 6, 2007! They also get a back stage pass to meet him. The package included two round trip tickets, a rental car, hotel for a week, new luggage, the concert tickets, and some spending cash! What a great trip for them! They both had to apply for passports. My niece has never had one and my sister has changed her last name since she last used hers.

I offered to make them wallets for their passports. I found two patterns on-line. The first one (it's the one I'm using) is from Husqvarna includes instructions, material list, and full size patterns pieces in a pdf file, Traveling Wallet. The second one is from Adorn Magazine. The pattern pieces for the Passport Wallet (pdf file) have to be enlarged. There are no instructions online. Instead you are referred to "For wallet instructions, see page 70, Adorn Summer ’07", but I think you could use the instructions and your own sewing skills to get you through it. Also, there are photos of this one here on Flickr. And I may just make them some luggage tags using this pattern from Janome.

I'll share the results with you when I finish. In the mean time, enjoy the music video below of Sir Elton John.
About New Zealand
Official Elton John website

Maggot Therapy

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

When I was a general surgery resident, we had a couple of patients come in with maggots in their wounds--both with venous stasis ulcers on their legs. As "icky" as it was to clean the maggots out of the wounds, it was down right impressive how clean the wounds were (and yes it was my job to do the cleaning). Those maggots sure had done a wonderful job of removing the necrotic tissue and leaving behind healthy granulation tissue.  So for Halloween, how about some bug therapy.

Maggot therapy waxes and wanes in popularity throughout time. Ambroise Pare (1509-1590) is generally given credit for first noting the beneficial effects of maggots in suppurative wounds. Napoleon's famous military surgeon, Baron D. J. Larrey (1766-1842) noted larvae of the blue fly in the wounds of soldiers in Syria during the Egyptian expedition. He noted that the maggots only attacked putrefying substances rather than living tissues and that they promoted their cicatrization. W. W. Keen commented on the presence of maggots in wounds during the Civil War, saying that the maggots were disgusting but did no apparent harm. The first scientific study of the use of maggots was done by Dr. William S. Baer of Baltimore, Maryland. He first mentioned this "viable antiseptic" for the treatment of chronic osteomyelitis in a discussion following an article by Bitting that appeared in 1921. Baer commented on the clean wound of two soldiers with neglected compound femur fractures and abdominal wounds who had lain neglected for 7 days on the battlefields of World War I in 1917. Inspection of the wounds showed that they were infected with thousands of maggots, but had healthy granulation tissue beneath. At that time, the mortality from such wounds with the best medical care was close to 75%, and therefore the maggots made a profound impression. He went on to study maggots in detail.

Maggots, by definition, are fly larvae, just as caterpillars are butterfly or moth larvae. Phaenicia sericata (green blow fly) larvae is the one used in maggot therapy. One-day-old larvae are only about 2 mm in length, and almost transparent. By the time the maggots are 3 or 4 days old, they have grown to about 1 cm (1/2 inch) long.

Maggot Therapy

Maggots may be used intentionally as biological debriding agents. They are an effective alternative to surgical debridement in patients who cannot go to the operating room for medical reasons. It is the larvae of the green blowfly (Phaenicia sericata) that is used. This larvae is sterilized with radiation before being used so that they will not be able to convert from the larvae to the pupae stage. They secrete enzymes that dissolve the necrotic tissue and the biofilm that surrounds bacteria. This forms a nutrient-rich liquid that larvae can feed on. Thirty larvae can consume 1 gram of tissue per day. They are placed on wounds and covered with a semipermeable dressing. The debridement is painless, but the sensate patient can feel the larvae moving. More importantly, maggots help to sterilize wounds, because they consume all bacteria regardless of their resistance to antibiotics (including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus). Maggots have to be replaced every 2 to 3 days. Maggot therapy can be administered on an outpatient basis, provided that visiting nurses are familiar with their use. This is a good technique for painlessly removing necrotic tissue and destroying antibiotic-resistant bacteria in patients who cannot undergo surgical debridement for medical reasons. They work well in infected and gangrenous wounds, with the best results reported in diabetic wounds.

Medical grade larvae are available from Zoobiotic Ltd and Monarch Labs.

HAVE A SAFE 'HAPPY HALLOWEEN'!

References

Maggot Therapy: The Surgical Metamorphosis; Plastic & Reconstructive Surgery. 72(4):567-570, October 1983; Pechter, Edward A. M.D.; Sherman, Ronald A. B.S.

From the Bible to Biosurgery: Lucilia sericata--Plastic Surgeon's Assistant in the 21st Century; Plastic & Reconstructive Surgery. 117(5):1670-1671, April 15, 2006; Whitaker, Iain S. M.A.Cantab., M.R.C.S.; Welck, Matthew M.B.Ch.B.; Whitaker, Michael J. M.A.Cantab.; Conroy, Frank J. M.R.C.S.

Maggot Debridement Therapy; Plastic & Reconstructive Surgery. 120(6):1738-1739, November 2007; Mumcuoglu, Kosta Y. Ph.D.

Clinical Approach to Wounds: Debridement and Wound Bed Preparation Including the Use of Dressings and Wound-Healing Adjuvants; Plastic & Reconstructive Surgery. Current Concepts in Wound Healing. 117(7S) SUPPLEMENT:72S-109S, June 2006 ; Attinger, Christopher E. M.D.; Janis, Jeffrey E. M.D.; Steinberg, John D.P.M.; Schwartz, Jaime M.D.; Al-Attar, Ali M.D.; Couch, Kara M.S., C.R.N.P., C.W.S.

Spider Veins

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

Just in time for Halloween--those "scary-looking" spider veins. (photo credit)

It is estimated that up to 50% of women by age 50 will have telangiectatic (spider veins) leg veins. It has been estimated that 10-20% of adults in the United States and Western Europe have varicose veins. The difference between varicose and spider veins is one of size. The tortuous veins greater than 4-5 mm in diameter are referred to as varicose. The veins between 1-4 mm in diameter are referred to as reticular, and the veins less than 1 mm in diameter are referred to as telangiectatia (spider veins). All three are the visible surface manifestations of an underlying venous insufficiency syndrome. Venous insufficiency syndromes allow venous blood to escape from a normal flow path and flow in a retrograde direction into an already congested leg.

"The most common scenario-- a single venous valve fails and creates a high-pressure leak between the deep and superficial systems. High pressure within the superficial system causes local dilatation, which leads to sequential failure (through over-stretching) of other nearby valves in the superficial veins. After a series of valves have failed, the involved veins are no longer capable of directing blood upward and inward. Without functioning valves, venous blood flows in the direction of the pressure gradient: outward and downward into an already congested leg. As increasing numbers of valves fail under the strain, high pressure is communicated into a widening network of dilated superficial veins in a recruitment phenomenon. Over time, large numbers of incompetent superficial veins acquire the typical dilated and tortuous appearance of varicosities. " (photo credit)

Common predisposing factors

• Family history
• Standing for long periods of time
• Pregnancy
• Age

History

• Common symptoms that should be elicited include leg heaviness, exercise intolerance, pain or tenderness along the course of a vein, pruritus, burning sensations, restless legs, night cramps, edema, skin changes, and paresthesias.
• Common symptoms of telangiectasia include burning, swelling, throbbing, cramping, and leg fatigue. Pain associated with larger varicose veins usually is a dull ache that is worse after prolonged standing
• Pain caused by venous insufficiency is often improved by walking or by elevating the legs in contrast to the pain of arterial insufficiency, which is worse with ambulation and elevation.

Physical:

Veins and their connections become gradually better defined through inspection, palpation, percussion, and hand-held Doppler examination to form a venous map that later guides treatment. The courses of all the dilated veins that are identified may be marked along the leg with a pen and later transcribed into the medical record as a map of all known areas of superficial reflux.

• The Perthes maneuver is a traditional technique intended to distinguish antegrade flow from retrograde flow in superficial varices. Antegrade flow in a variceal system indicates that the system is a bypass pathway around deep venous obstruction. This is critically important because, if deep veins are not patent, superficial varices are an important pathway for venous return and must not be sclerosed or surgically removed.
• The Trendelenburg test can often be used to distinguish patients with superficial venous reflux from those with incompetent deep venous valves.
• Doppler examination is an adjunct to the physical examination that can directly show whether flow in a suspect vein is antegrade, retrograde, or to-and-fro.

TREATMENT

SCLEROTHERAPY
Sclerotherapy is the introduction of a foreign substance into the lumen of the vein to cause thrombosis and subsequent fibrosis.

Chemical Irritants produce direct destruction of the endothelial cells.

• Glycerin--for use in veins less than 1 mm in diameter
• Polyiodinated Iodine

Hypertonic solutions produce dehydration of endothelial cells through osmosis, resulting in endothelial destruction.

• Hypertonic-saline 11.7% --for use in veins less than 1 mm in diameter
• Hypertonic-glucose

Detergent sclerosants produce endothelial damage through interference with the cell's surface lipids.

• Sodium morrhuate
• Sodium tetradecyl sulfate, 0.25% used in veins less than 1 mm in diameter; 0.25-0.5% used in 1-4 mm veins; and 1-3% used in veins 4-10 mm in diameter
• Ethanolamine oleate
• Polidocanol foam, 0.5 % used in veins less than 1 mm; 0.5-1% used in veins 1-4 mm; and 2-5% used in veins 4-10 mm in diameter

Postsclerosis compression is important for multiple reasons, one of which is to support the untreated vessels while the sclerosed vessels heal/scar. (photo credit)

MINIPHLEBECTOMYMiniphlebectomy or ambulatory phlebectomy allows removal of short segments of varicose and reticular veins through tiny incisions using special hooks developed for the purpose. This procedure is extremely useful for the treatment of residual clusters after saphenectomy and for removal of nontruncal tributaries when the saphenous vein is competent.

TRANSCULTANEOUS LASER AND INTERMITTANT PULSED LIGHT (IPL) have proven effective for the tiniest surface vessels (eg, those found on the face), but this modality is not generally useful as primary therapy for treatment of spider veins of the lower extremity. For most patients, the laser pulses are significantly more painful than the 30-gauge needles used for microsclerotherapy. Most spider veins of the legs have associated feeding vessels that must be treated by some other means before the tiny surface vessels are amenable to laser or IPL treatment.

LASE (Laser assisted Saphenous Endoablation)
The procedure was pioneered in 1999 by Dr. Robert Min and Dr. Luis Navarro in conjunction with Diomed. The technique continues to be refined and enhanced today reflecting Diomed’s ongoing commitment to the science and practice of vein management. EVLT® is a minimally invasive, clinically proven alternative to surgical vein stripping that effectively and safely treats varicose veins using a diode laser fiber to occlude the vein. (photo credit)

LIGATION
Some problems, such as large varicose veins, may call for ligation, a procedure in which the connections between the damaged veins and the normal vein systems are interrupted. Saphenectomy with saphenofemoral ligation is a traditional approach that is most often performed using an internal stripping tool and an invagination technique.

Complications:

• Complications of varicose disease include venous ulcers, variceal bleeding, and venous thromboembolism.

• Potential complications of treatment include anaphylaxis, changes of pigmentation, ulcerations, paresthesias, arterial injury, and venous thromboembolism.

PREVENTION --Activity is a strong protective factor against venous stasis. So I would encourage all of you to move--walk, dance, fidget. Be active.

• Pregnant patients and those with a strong family history of varicose disease may prevent, delay, or ameliorate the problem by wearing 30-40 mm Hg gradient compression hose whenever standing.

• Constant use of compression hose can prevent the worsening of existing varicose disease that cannot be treated immediately

References
Varicose Veins and Spider Veins--Women's Health.gov
Varicose Veins and Spider Veins by Craig Feied, MD--eMedicine Article
No More "Spider Veins" by Michel P Goldman, MD--Plastic Surgery Products Newsletter, October 2007
Varicose Veins--Mayo Clinic
Spider Veins (Sclerotherapy),Diminishing Unsightly 'Spider Veins'--American Society of Plastic Surgeons
Minimally Invasive Venous Intervention Procedure (OR-Live)--Morristown Memorial Hospital (requires media player, 1 hour program)
Treatment of Varicose Veins through Laser Surgery (OR-Live)--Nebraska Medical Center (requires media player, 1 hour program)
Site with good before and after photos--Veintec Varicose Vein Clinic

Glomus Tumor

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

A glomus tumor is a rare benign tumor of the hand. It constitutes 1–5% of the soft-tissue tumors in the hand. It arises from the glomus body which is a neuromyoarterial apparatus described by P. Masson in 1924. The normal glomus body is an arteriovenous shunt that is composed of an afferent arteriole, an anastomotic vessel (Sucquet-Hoyer canal), a collecting vein, and a capsular portion. It resides in the stratum reticulum of the skin. There are large numbers in the subungual region and in the distal pad of the digits. The glomus body is a controlled arteriovenous anastomosis or shunt between the terminal vessels thought to be important in regulating peripheral blood flow in the digits, which secondarily controls peripheral blood pressure and body temperature. (photo credit)

Glomus tumors affect women two to three times more often than men. Most are in the 30-50 year age group. Most occur in the subungual area (approximately 50%), but can occur on the finger tip pulp, the palm, wrist, forearm and foot. Glomus tumor can occur near the tip of the spine, where it may arise from the glomus coccygeum. Glomus tumors have also been described in locations where the glomus body does not normally occur. These unusual sites include the patella, bone, chest wall, eyelid, colon, rectum, and cervix. Over 75% of glomus tumors occur in the hand.

Symptoms usually consist of a triad

• severe paroxysmal pain--the pain can be excruciating and is described as a burning or bursting
• localized tenderness
• extreme cold sensitivity

Physical exam reveals a blue-pink tender mass that can often be seen through the nail plate or skin. When the mass is growing beneath the nailbed (subungual), it can displace the nailbed dorsally. (photo credit) When the lesion is beneath the nail matrix, it can produce a longitudinal ridging of the nail plate. Placing the involved digit or extremity in ice water will reproduce the pain within 60 seconds. Typically, the mass is usually less than 7 mm in diameter, so can be very difficult to palpate even when not beneath the nail. There are two clinical findings described, particularly in relation to the painful subungual solitary glomus tumors. They are the Hildreth's sign and Love's test. Hildreth's sign is disappearance of pain after application of a tourniquet proximally on the arm. Love's test consists of eliciting pain by applying pressure to a precise area with the tip of a pencil. Routine laboratory studies have no role in diagnosis of glomus tumor.

X-rays of the finger may show bone erosion, ranging from a small concave defect to a sharply defined radiolucent lesion seen in the region of the tuft of the phalanx. There is often a thin sclerotic margin about the defect as a secondary reaction to the tumor pressure. Standard magnetic resonance imaging (MRI) can be used to detect glomus tumors. (photo credit)

The tumor consist of a highly organized, well-encapsulated mass consisting of glomus cells, curled blood vessels, and a large number of nerves within or adjacent to the lesion. This explains the great sensitivity of the glomus tumor.

Treatment is surgical. Surgical approach will vary depending on the location of the tumor. The glomus tumor is always well encapsulated and can usually be "shelled out" with little or no difficulty. When excision is complete, the prognosis is excellent for full recovery with no recurrence.

References

Glomus Tumor by Henry DeGroot, III MD--bonetumor.org

Glomus Tumor at Wheeless Textbook of Orthopedics

Subungual glomus tumor by Dr. K.-- MSKcases

Glomus Tumor of the Finger Tip and MRI Appearance by David H Kim, MD--Iowa Orthop J. 1999; 19: 136–138.

Two cases of subungual glomus tumor; Murthy PS, Rajagopal R, Kar PK, Grover S; Indian J Dermatol Venereol Leprol 2006;72:47-9

Glomus Tumor by Michael B Reynolds, MD--eMedicine Article

SurgeXperiences 107 is Up!

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

The bi-weekly surgery carnival is up over at Vitum Medicinus. The author is a "23-year-old in his second preclinical year at a Canadian medical school." There are some interesting links. (photo credit)

Humane Society Day Planner

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

Our local humane society (Pulaski County Humane Society) began publishing a Day Planner in 2005. It has turned into a very good fund raiser for them. Last night was the debute of the 2008 seen here. I ordered several that first year to give as Christmas presents. They were such a big hit the first year, I've had to keep doing it.

The first year (2005) we put a picture of my first "true" pet--Columbo-- in the calendar. He had died in November 2002 at age 9 yrs from a strange abdominal cancer. Despite both human and veterinarian pathologist looking at the slides, no diagnosis could be given other than a malignancy. He was an extremely cool dog!

He would carry 5 gallon buckets around the yard, roll the bucket,

and toss it in the air with his head.

He loved to catch soccer balls as they bounced off the roof.

The next year (2006) we put Ladybug's photo in. I posted about her here. She died in May 2002 from osteosarcoma of her left maxilla. The "thing" in her mouth is a rolled up raw hide, not a cigar. She was quite the charmer!

This past year (2007) we had Girlfriend's photo in the calendar. We lost her this year to a canine hemangiosarcoma. I still can not make myself change my profile to say I only have one dog rather than two. I will do it someday, but not today. I still miss her too much. I keep having to correct myself when I tell someone I'm "off to walk my dogs".

This year (for 2008) we had two sets of photos put in. One for our neighbors who lost their beloved Maggie, a border collie, to old age. And the other for my brother and his wife (who live in South Carolina)--someone had poisoned several of their dogs by adding anti-freeze to some food and giving it to the dogs. In the calendar, the photos are placed on two memorial pages (didn't photograph well for me to show you).

Next year my husband says is Rusty's year. I've got to work on getting a really good picture of him. He too is a character! Check out this video of him "playing" basketball.

Striae (Stretch Marks)

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

I am often asked "What can I do to get rid of my stretch marks?" The short (honest) answer is nothing. Stretch marks are scars. The longer answer is addressed here---causes and ways to improve their appearance. 

Striae distensae (stretch mark) is a common skin condition. It rarely causes any significant medical problem. However, striae can be of significant emotional distress to those affected. They represent linear dermal scars accompanied by epidermal atrophy. (photo credit) 

Stretch marks affect skin that is subjected to continuous and progressive stretching. Common predisposing circumstances for the development of stretch marks include: those which involve a physical stretching of the skin, such as rapid weight gain or adolescent growth spurts, and others that involve hormonal changes, such as chronic steroid medication use or Cushing syndrome (increased adrenal cortical activity). Genetic factors could certainly play a role, although this is not fully understood.[I have never seen stretch marks occur from augmentation mammoplasty or soft tissue expanders, nor are they ever listed as a possible complication of those surgeries.] 

Regardless of their causes, all stretch marks follow a natural course of progression. An early sign of stretch marks developing is when an area of skin becomes flattened and thin with a pink color. The area may occasionally be itchy. Soon reddish or purplish lines develop (striae rubra). Over time these lighten to become whitish or flesh-colored and much less conspicuous. Stretch marks are usually several centimeters long and 1-10 mm wide. Those caused by corticosteroid use or Cushing's syndrome are often larger and wider and may involve other regions, including the face. 

How are they treated?

There are many treatments available, ranging from therapy applied to the skin, laser therapy, and even more invasive surgical methods. Unfortunately, stretch marks remain a tricky problem to target, in which no established treatment exists. Recent studies have evaluated laser treatment on stretch marks of various ages, topical 0.1% tretinoin cream applied to early clinically active stretch marks, and treatment of mature stretch marks with two different topical regimens (including glycolic acid, L-ascorbic acid, zinc sulfate, and tyrosine vs glycolic acid, and tretinoin emollient cream). Treatment with laser and treatment with glycolic acid in combination with 0.05% tretinoin emollient cream appeared to increase the elastic content in the treated lesions, improving the appearance of the striae. (Please, note none of these treatments remove the stretch mark. They only improve the appearance of the stretch mark.) In particular, clinical improvement in the laser treated group continued for 6 months or more after treatment.

The left photo is prior to treatment with tretinoin 0.1% cream, the right is after 8 weeks of treatment (same person). I don't really appreciate the improvement, do you? photo credit

The only way to truly remove (or get rid of) a stretch mark is to surgically excise it. If your stretch marks happen to "sit" in the area of your central lower abdomen, then you may be able to have yours removed by an abdominoplasty. Most of us aren't that fortunate. Many of us have them on our hips or outer thighs from puberty. If you are a teenager, the stretch marks you have now that are in that bright pink or purple stage will fade. That alone will make them less visible. 

Be careful if someone promises to completely get rid of or erase your stretch marks. There is no proven way to do so at this time.

References
Striae Distensae by Samer Alaiti, MD--eMedicine article
Stretch marks (striae)--DermNet NZ
Stretch Marks by Patrice Hyde, MD--Kid's Health article
Stretch Marks--Virtual Medical Centre
Photo Gallery of Stretch Marks
Derm Atlas--Stretch Marks

Poststernotomy Mediastinitis and Repair

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

In the United States, mediastinitis most commonly occurs in the postoperatively. It occurs in 1-2% of patients who have a sternotomy. Most of these patients are cardiac surgery patients (more than 300,000 cases per year in the US). Most of these are coronary bypass patients rather than heart valve or transplant patients. Some other causes of mediastinitis, other than postoperative, include 1) esophageal perforation; 2) trauma, especially blunt trauma to the chest or abdomen; 3) tracheobronchial perforation, due to either penetrating or blunt trauma or instrumentation during bronchoscopy; 4) descending infection following surgery of the head and neck, great vessels, or vertebrae; 5) progressive odontogenic infection (Ludwig angina); 6) mediastinal extension of lung infection; and 7) chronic fibrosing mediastinitis due to granulomatous infections. (photo credit)

Mediastinitis is a life-threatening condition with an extremely high mortality rate if recognized late or treated improperly. Although small in proportional terms (one out of one hundred post-sternotomy), the actual number of patients affected by mediastinitis is substantial (1% of 300,000 equals 3000). This significantly increases mortality and cost.

Even though poststernotomy mediastinits is considered by the Department of Health and Human Services as a "never event" it will still occur. Hopefully, it will decrease to a much smaller (though I doubt ever be a "never") in number event. Prevention guidelines—The CDC surgical site infection prevention guidelines are backed by evidence based medicine. 

Risk factors for the development of mediastinitis postoperatively include the following:

• Bilateral internal mammary artery grafts
• Diabetes mellitus
• Emergency surgery
• External cardiac compression (conventional cardiopulmonary resuscitation)
• Obesity (>20% of ideal body weight)
• Postoperative shock, especially when multiple blood transfusions are required
• Prolonged bypass and operating room time
• Reoperation and/or Reexploration following initial surgery (check out Grunt Doc's post)
• Sternal wound dehiscence
• Surgical technical factors (eg, excessive use of electrocautery, bone wax, paramedian sternotomy

TREATMENT
Medical

Most patients have already received prophylactic antibiotics, usually a first-generation cephalosporin. Very broad and deep antibiotic coverage that includes Pseudomonas species (20% are gram negative) and methicillin-resistant S aureus (20% are MRSA) is needed. Culture results should then guide antibiotic use as multiple regimens are available for use with patients who have mediastinitis. Therapy is usually prolonged, ranging from weeks to months (4-6 weeks of therapy is adequate for most patients). Nutritional support is often necessary. This may be enteral or hyperalimentation.

Surgical options for mediastinitis after cardiac surgery
Effective treatment for simple sternal dehiscence without infection is rewiring the sternum. This usually yields reasonable long-term results. Cultures should be taken to exclude active infection in the cases of sternal dehiscence.

Failure to adequately debride and sterilize the mediastinum during the first reoperation is the most common cause of repeat postoperative mediastinitis. Options for mediastinitis after cardiac surgery are immediate closure after sternal debridement, delayed closure after sternal debridement, and sternal irrigation after sternal debridement. Each has its advantages and disadvantages. The best strategy for accomplishing this depends on the duration of the infection, the condition of the mediastinal structures, and the experience of the surgeon. Below is a diagram of the main pathways for treatment selection as per the presenting wound as per Dr. Norman Schulman (reference 3).

Most surgeons prefer to leave the wound open for subsequent debridement efforts after initial sternal reexploration. In this case, the wound is packed daily until it appears clean with adequate granulation tissue. At this point, muscle flap closure is achieved. The workhorse flap is the unipedicled pectoralis major muscle flap. It is based on its primary blood supply from the acromioclavicular axis. By detaching the muscle from its sternal, rib, humeral, and medial clavicular attachments and separating it from the clavicular head of the deltoid, it can usually be extended to the level of the xiphoid. Back cutting the superior medial segment of the pectoralis muscle for a distance of 4 to 6 cm maintains its blood supply and permits it to be tucked into an upper manubrial dead space. Distal closure at the level of or below the xiphoid is accomplished by approximating the upper medial ends of the rectus sheath with large no. 1 sutures. (photo credit)

Although many closures are accomplished with a single pedicled pectoralis flaps both muscles may be used if necessary on their respective pedicles to provide extensive coverage for the heart and the sternal defect and particularly exposed grafts. Many bypass patients have had the left and on occasion the right internal mammary arteries taken, thus limiting the use of “turnover” pectoralis flaps, which rely on perforators from these arteries. The rectus muscle is very hardy and can provide excellent coverage of sternal defects, especially those involving the lower sternal areas.

Recently, vacuum-assisted closure has been used alone or in conjunction with muscle flap closure for mediastinitis in an attempt to decrease the incidence of this bleeding.

The lack of a bony anterior sternal wall may be unacceptable to some patients and has prompted some surgeons to attempt sternum-sparing procedures, even in more advanced cases. This is often a difficult decision, requiring excellent surgical judgment. Advanced cases of sternal osteomyelitis are extremely difficult to cure, and most patients with muscle or omental flaps do very well from a functional standpoint.

Vacuum-Assisted Closure Photo credit.

Vacuum assisted closure (also called vacuum therapy, vacuum sealing or topical negative pressure therapy) is a sophisticated development of a standard surgical procedure, the use of vacuum assisted drainage to remove blood or serous fluid from a wound or operation site. A piece of foam with an open-cell structure is introduced into the wound and a wound drain with lateral perforations is laid on top of it. The entire area is then covered with a transparent adhesive membrane, which is firmly secured to the healthy skin around the wound margin. When the exposed end of the drain tube is connected to a vacuum source, fluid is drawn from the wound through the foam into a reservoir for subsequent disposal.

The plastic membrane prevents the ingress of air and allows a partial vacuum to form within the wound, reducing its volume and facilitating the removal of fluid. The foam ensures that the entire surface area of the wound is uniformly exposed to this negative pressure effect, prevents occlusion of the perforations in the drain by contact with the base or edges of the wound, and eliminates the theoretical possibility of localised areas of high pressure and resultant tissue necrosis. 

References

Part II, Department of Health and Human Services Centers for Medicare & Medicaid Services ; 42 CFR Parts 411, 412, 413, and 489 Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule --surgical infections

Mediastinitis by Dale K Mueller, MD--eMedicine article

Sternal Wound Reconstruction: 252 Consecutive Cases. The Lenox Hill Experience; Plastic & Reconstructive Surgery. 114(1):44-48, July 2004; Schulman, Norman H. M.D.; Subramanian, Valavanur M.D.

Chest Reconstruction, Sternal Dehiscence by Sanjay K Sharma, MD--eMedicine article
Bipedicle Muscle Flaps in Sternal Wound Repair; Plastic & Reconstructive Surgery. 101(2):356-360, February 1998; Solomon, Mark P. M.D.; Granick, Mark S. M.D.

Use of the Omentum in the Management of Sternal Wound Infection after Cardiac Transplantation; Plastic & Reconstructive Surgery. 95(4):697-702, April 1995; Wornom, Isaac L. III M.D.; Maragh, Hallene M.D.; Pozez, Andrea M.D.; Guerraty, Albert J. M.D.

Mechanisms Governing the Effects of Vacuum-Assisted Closure in Cardiac Surgery; Plastic & Reconstructive Surgery. 120(5):1266-1275, October 2007; Malmsjo, Malin M.D., Ph.D.; Ingemansson, Richard M.D., Ph.D.; Sjogren, Johan M.D., Ph.D.

An introduction to the use of vacuum assisted closure by Steve Thomas, PhD--World Wide Wounds

Over the Jumps Carousel

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

Arkansas is lucky to have a very unique carousel--"Over the Jumps". It is one of only four "over the jumps" carousels made by Herschell-Spillman in the 1920's. It is the only one left in working condition. Sixteen years ago a group of Arkansans called Friends of the Carousel formed to save and restore the horses, scenery panels, and machinery to their original splendor. Yesterday, the carousel reopened at its new home, the Little Rock Zoo. It is a carousel that many of us remember riding as children when it was located at the War Memorial Park. Now I (and many others) will be heading to the zoo to ride again. (photo credit) 

History of the Carousel

The heyday of carousels in the United States was from 1887 to 1935. It is estimated that approximately 8,000 were produced during this time, with less than 150 surviving today. Many of those have not been restored. The Over the Jumps, (the Arkansas Carousel), is even rarer because of its undulating track. The track goes up and down rather than the horses so it is similar to a roller coaster. It was constructed in 1924 as a traveling carousel by the Herschell-Spillman Engineering Corporation of North Tonawanda, New York.

The Arkansas Carousel made its first appearance at the 1924 Arkansas State Fair as part of a traveling circuit of amusement rides. Tom Fuzzell, a Little Rock resident bought it in 1942 and housed it in a shelter constructed from one of the original state fair buildings. The purchase saved the ride from destruction and it continued to entertain Arkansans and visitors alike. It was also placed on the National Register of Historic Places as being of state significance in 1989. (Just recently it was added to the Register because of having national importance.) In 1991 owners Mokie Shotes and Doc O'Kelley decided to sell it.
At the time, there was no guarantee the priceless amusement piece would stay together, much less in The Natural State. Little Rock and Arkansas were in real danger of losing it to out-of-state interests, including some as far away as Great Britain. Then Little Rock resident Marlena Grunewald and at the time Senator Mike Kinard, acting separately, decided something had to be done to save the Little Rock landmark. The two eventually joined forces and formed the Friends of the Carousel group, which collected enough donations to make a down payment, keeping it off the auction block. (photo credit)

The initial plan was to restore the ponies, four chariots, and 24 large wooden wheels by just touching up the existing paint. Once the work began, however, it developed into much more as 40 layers of paint were discovered; it became a conservation project. There are 40 ponies, two of which were added at a later date and are not a part of the original carousel, though they were manufactured by the same company. These two, Smarty Jones and Ginger, will be restored at a later date. Smarty is named after the famous thoroughbred and was adopted by the real Smarty’s owners, Chappy and Pat Chapman. Ginger is named in honor of Ginger Murry of Murry's Dinner Playhouse in Little Rock. All the original animals have one of two poses -- heads up or heads down -- and are either an inside or an outside horse. The exterior ponies are more ornately carved and bejeweled, while the interior ones are less decorated but are slightly larger in size. The majority of the restoration work on the horses and chariots has been done by well-known conservator Rick Parker of Gentry, Arkansas. The large wooden wheels were redone by an Amish wheelwright of Bird-in-Hand, Pennsylvania.

FOC Chairman David Martinous of Little Rock estimates the total restoration cost including the mechanicals, to be around $1 million dollars. According to Little Rock Deputy City Attorney Cindy Dawson, who is a FOC board member and serves as legal counsel to the zoo's board of governors, "It has been expensive to go the original restoration route, for sure. It would have been cheaper to have done the 'dip and strip' and paint route, but the decision to restore the original was made by the founding members of the group so the subsequent members have continued on the same path."

When completed, Over the Jumps will be the focal point of a new entry complex at the Little Rock Zoo. The entrance will have an elegant Gay '90s feel with a gift shop, an old-fashioned ice cream parlor, visitor services, formal gardens, and a replica of "Laughing Sally," a coin-operated fortune teller long associated with the carousel when it was at Little Rock's War Memorial Park. Zoo Director Mike Blakely says plans call for the carousel to be open during evening football games at War Memorial Stadium.

Needless to say, all of those of us who enjoyed this classic as a child are eagerly awaiting the unveiling of the final results. Blakely estimates the ceremony to be in May but with a great deal of luck and good weather, it might be April. In honor of this momentous occasion, the Clinton Presidential Center and Park in downtown Little Rock will have a temporary exhibit of the restored horses April 8-30 entitled "Over the Jumps: The Arkansas Carousel." No matter when the grand unveiling of the totally refurbished antiquity takes place, I'll hazard a guess there will be quite a few adults riding the Arkansas Carousel that day -- and for many days to come.

KATV Video on history of the carousel

Dressings for Acute and Chronic Wounds

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

A strong consensus was reached for use of the following combinations: for chronic wounds, (1) debridement stage, hydrogels; (2) granulation stage, foam and low-adherence dressings; and (3) epithelialization stage, hydrocolloid and low-adherence dressings; and for the epithelialization stage of acute wounds, low-adherence dressings," the review authors write. "For specific situations, the following dressings were favored: for fragile skin, low-adherence dressings; for hemorrhagic wounds, alginates; and for malodorous wounds, activated charcoal."

Chronic wounds were defined as those expected to take more than 4 to 6 weeks to heal because of 1 or more factors delaying healing, including venous leg ulcers, pressure ulcers, diabetic foot ulcers, extended burns, and amputation wounds. Acute wounds were defined as those expected to heal in the expected time frame, with no local or general factor delaying healing. These included burns, split-skin donor grafts, skin graft donor site, sacrococcygeal cysts, bites, frostbites, deep dermabrasions, and postoperative-guided tissue regeneration. Summary from the MedScape article by Dr. Laurie Barclay. 

So what are these dressings? What is a hydrogel? or an alginate?

HYDROGELS

Hydrogel dressings are composed mainly of water in a complex network that keep the cross-linked polymer gels intact. The water is released to provide and maintain a moist wound environment. By increasing moisture content, hydrogels have the ability to help cleanse and debride necrotic tissue. Hydrogels are non-adherent and can be removed without trauma to the wound. Hydrogel dressings are not very absorptive, and therefore are not the appropriate choice for moderate to highly exudating wounds. Hydrogel dressings often require secondary dressings for this reason. Hydrogel dressings can be shaped into gauze, sheets, or filler material.

• Tegaderm Hydrogel Wound Filler (3M)
• Intrasite Gel (Smith & Nephew)
• VIGILON Primary Wound Dressing (Bard Medical)
• FlexiGel Strands Absorbent Wound Dressing (Smith and Nephew)--photo credit

SYNTHETIC FOAM DRESSINGS

These dressings were designed to absorb large amounts of exudates and to maintain a moist wound environment. They are not as useful as alginates or hydrocolloids for debridement. They should not be used on low or non-exudating wounds as they will cause dryness and scabbing.

• Allevyn (Smith & Nephew) (photo)
• Lyofoam (Convatec)
• Tegaderm Foam Dressing (3M)

HYDROCOLLOID DRESSINGS

Hydrocolloids are sterile wound dressings, which consist of a hypoallergenic, hydrocolloid adhesive with an outer clear adhesive cover film impermeable to liquids, bacteria and viruses. The inner layer of hydrocolloid adhesive rapidly absorbs exudate. The breathable outer film layer provides for a high rate of moisture vapor transmission. Together, these features ensure an optimal moist wound environment, minimize the chance for damage to healthy skin surrounding the wound and provide extended wear for up to seven days. (photo credit)

• DuoDERM (Convatec)
• Tegaderm Hydrocolloid Dressing (3M), regular and thin

LOW ADHERENCE DRESSINGS

The use of low or non-adherence dressing materials will minimize disruption of healthy granulation tissue and re-epithelialized surfaces.

• Jelonet Paraffin Gauze Dressing (Smith & Nephew) is a low-adherent tulle dressing that allows the wound to drain freely into an absorbent secondary dressing.
• Tegaderm Non-Adherent Contact Layer is a woven nylon fabric with sealed edges that is a lint-free, non-adherent, non-toxic, non-irritating, and hypoallergenic material. It can be left on the wound for up to 7 days. This contact layer can be used under gauze or other absorbent dressings. It will allow exudates to pass through to an absorbent outer barrier. The non-adherence of this material will minimize disruption of healthy granulation tissue and re-epithelialized surfaces. (photo credit)
• Paranet "Vernaid" Sterile Paraffin Gauze Dressing BP

ALGINATE DRESSINGS

These dressings are sterile, highly conformable, and absorbent primary wound dressings for use on moderately to heavily exudating wounds. They are composed of calcium alginate which is a seaweed component. When the dressing is in contact with wound, the calcium in the dressing is exchanged with sodium from the wound fluid and this turns dressing into a gel that maintains a moist wound environment. It is a good dressing for exudating wounds and helps in debridement of sloughing wounds. It should not be used on low exudating wounds as this will cause dryness and scabbing. This dressing should be changed daily. (photo credit)

• Kaltostat (Convatec)
• Sorbasan (Bertek Pharm)
• Tegaderm Alginate High Integrity Dressings (3M)
• Tegaderm High Gelling Alginate Dressing (3M)

The activated charcoal products are for stoma bags to decrease or elimate the odor from the collected urine or feces. The article at DermNet NZ on skin problems from stomas is very well written.

References
Dressings for Acute and Chronic Wounds--A Systematic Review; Arch Dermatol. 2007;143:1297-1304; Olivier Chosidow, MD & others (can access online if AMA member)
Consensus Statement Describes Dressings for Acute and Chronic Wound Management--MedScape article by Laurie Barclay, MD
Wound Dressings--Family Practice Notebook
Synthetic wound dressings at DermNet NZ
Skin problems from stomas at DermNet NZ

SurgeXperience 107--call for submissions

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

Vitum Medicinus is hosting SurgeXperiences 107 on October 28, 2007. Submissions will be accepted via a Blog Carnival. Click here to submit your blog post. Please submit your surgery related posts (surgeon, nurse, patient, etc viewpoints welcome). It is meant for learning and sharing. (photo credit) SurgeXperience home can be found here.