Category Archives: Plastic Surgery

Do Medical Tattoos Need Guidelines?

Should medical tattoos be standardized? Should there be guidelines pertaining to their design, and where on the body they’re located? Should physicians prescribe tattoos to patients with hidden medical conditions? And if the answer to any of those questions is yes, should medical personnel be the ones doing the tattooing?

Photo by Miriam E. Tucker / Used with permission

Those were among the questions raised by Dr. Saleh Aldasouqi in a poster presentation and at a press briefing at the annual meeting of the American Association of Clinical Endocrinologists.

Some patients with diabetes and other hidden medical conditions are choosing to be permanently tattooed rather than wear a necklace or bracelet to alert emergency personnel of their conditions. This is particularly common among patients with type 1 diabetes, for whom low blood sugar can result in unconsciousness or odd behavior that can easily be mistaken for drunkenness.

“There are a lot of patients with diabetes who are getting tattoos. Just Google ‘medical tattoos’ or ‘diabetic tattoos’ and you’ll find a large number from around the world.  The problem is they’re not consulting their physicians. They could have high sugar, which can affect wound healing. …There are so many issues now being talked about with regard to medical tattooing,” noted Dr. Aldasouqi, an endocrinologist at Michigan State University, Lansing.

He believes these issues should be addressed by professional medical organizations, possibly including those pertaining to diabetes, dermatology, and emergency medicine.

As for tattoo location on the body,  the wrist would be the most logical place since first responders will always check there, he said.

So who should do the tattooing?  Tattoo parlors that are licensed under state or local laws are typically clean and use sterile equipment, and require customers to read and sign consent forms that address medical conditions and risks.  Of course, tattoo artists would need to be educated about any new standard.

But dermatologists or plastic surgeons could do it as well. “We’re not competing with tattoo artists, but at least we can collaborate with them by standardizing at their level, or make it a minor surgical procedure. In fact, this is being done to mark the skin for radiation therapy in cancer patients, and in reconstructive surgery after breast cancer. Some medical tattooing is already being done  by medical specialists. So, it’s open for discussion.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

Leave a comment

Filed under Allergy and Immunology, Dermatology, Emergency Medicine, Endocrinology, Diabetes, and Metabolism, Family Medicine, Health Policy, Hospital and Critical Care Medicine, IMNG, Infectious Diseases, Internal Medicine, Plastic Surgery, Primary care, Uncategorized

The Facelift Serenity Prayer

If there ever were a field in which it’s easy to overdo things, it’s aesthetic medicine. In fact, some clinicians develop what Dr. Val S. Lambros calls “surgeon dysmorphia syndrome,” which occurrs when “the surgeon thinks something looks so good that he makes everyone look that way.”

At the Summit in Aesthetic Medicine 2011 meeting in Dana Point, Calif., Dr. Lambros shared a version of the Serenity Prayer that he modified as a way to remind his colleagues to avoid developing that syndrome. Known as the Facelift Serenity Prayer, it reads:

Grant me the ability to change the things I can,

The serenity to let go of the things that I can’t,

And the wisdom to avoid overdoing the things I can change to fix the things I can’t.

Dr. Lambros, a clinical instructor at the University of California, Irvine, Aesthetic and Plastic Surgery Institute, said that he created the prayer prior to addressing a group of plastic surgeons about 4 years ago.

“It really could be called the Cosmetic Surgery Serenity Prayer,” he said.

— Doug Brunk (on Twitter@dougbrunk)

Leave a comment

Filed under Dermatology, IMNG, Plastic Surgery

Laser-Assisted Liposuction Gets Burned

It happens to me all the time at medical conferences: I scramble to get myself to a meeting room, squeeze myself past aisle-seat squatters (you know who you are), get settled, pull out my notebook, and realize with the introduction of the first speaker that I’m in the wrong place. I then either  get to where I need to be or just stay put, either because there’s no easy way out or I hear or see something that piques my interest.

The latter happened yesterday at the annual meeting of the American Society for Aesthetic Plastic Surgery in Boston, when I found myself in scientific session A – “Lipoplasty: It’s Us, Not the Machine” – instead of scientific session B – “The Face – Fillers vs. Fat.”

Image courtesy of Wikimedia user Anarkangel by Creative Commons License

Anticipating an industry-sponsored feel-good fest dominated by slide after slide of before and after success stories, I started gathering up my gear to make my escape, when something unexpected happened. One of the panelists, Dr. Simeon Wall of the Wall Center for Plastic Surgery in Shreveport, Louisiana, slammed laser-assisted liposuction, which, since its arrival on the scene in 2007, has been touted as being a more effective, more efficient fat removal technology than traditional liposuction, resulting in less bruising and swelling and quicker recovery times, along with improvements in skin tightness and the appearance of cellulite. In fact, Dr. Wall stated, based on a review of the published literature, these claims “have no scientific basis,” even though the technology is FDA-approved and the machines have been on the market for a few years.

Intrigued, I decided to stay put for a few minutes to hear what some of the other panelists had to say, thinking a potentially interesting debate might ensue. I was half right. What followed was interesting, but there was no debate. In fact, the panelists were mostly in agreement with Dr. Wall’s assessment.

Dr. Constantino Mendieta, who is in private practice in Miami, referred to the laser liposuction device in his office as a “very expensive dust collector. It just doesn’t work.” Panel moderator Dr. Steven Teitelbaum of Santa Monica, Calif., suggested that the few good results achieved by select surgeons who are extraordinarily proficient with the device are exceptions to the norm and that the rate of dangerous complications associated with the technology outweigh the remote chance of substantial benefit.

In response to a lament from a session attendee in the audience that the majority of the revisional liposuction cases he sees in his practice are the result of laser-assisted liposuction, Dr. Wall agreed, and noted that the deformities associated with laser-assisted liposuction are typically “more difficult to correct” than those associated with other liposuction methods.

Although the session was filled with the expected collection of before-and-after shots achieved using a range of liposuction methods (some of the differences were impressive; some barely discernable), I was glad I stayed. The laser lipo-bashing was informative and entertaining, and the session seemed to lend credence to the stated theme of this year’s ASAPS meeting: “Affirming the Science of Aesthetic Surgery,” although the corollary – “Debunking the Hype” –  might have been a more appropriate moniker. Either way, it was well played. 

— Diana Mahoney

2 Comments

Filed under Blognosis, Dermatology, Drug And Device Safety, IMNG, Internal Medicine, Plastic Surgery, Surgery, The Mole

Whose Rights Are at Stake?

The Supreme Court heard arguments Tuesday in support of the 2007 Vermont statute limiting the release of the information detailing which drugs doctors prescribe. This information is maintained by pharmacies, which sell it to data-mining agencies, that in turn sell it to drug companies, for marketing purposes. Patient information is excluded from the data, doctor’s information is not.

Under the Vermont law, this information can be released only with the consent of the doctor. However, once data collection firms like IMS Health and interested parties like Pharmaceutical Research Manufacturers of America, challenged the statute, the issue became a question of free speech.

In the case of Sorrell v. IMS Health Inc., data-mining firms claim they have First Amendment rights to buy and sell the information for their marketing use.

However, the state’s attorney’s office likened the release of the confidential information to disclosing a doctor’s tax returns, patient files, or a competitor’s business information, arguing that First Amendment rights in the case apply to protecting doctor’s information. But since the information is given away to parties including insurance companies, journalists, and law enforcement, the court wasn’t too convinced.

” … just don’t tell me that the purpose is to protect their privacy,” said Justice Antonin Scalia. “[A doctor's] privacy isn’t protected by saying you can’t sell it but you can give it away.”

Justice John Roberts said Vermont is trying to reduce health care costs by “censoring” information doctors hear about brand-name drugs, with the intent that they will prescribe more generics, a measure Justice Scalia added was a restriction on free speech.

Vermont Assistant Attorney General Bridget Asay responded that “the purpose of the statute is to let doctors decide whether sales representatives will have access to this inside information” on the prescribing habits of physicians.

Attorneys general of several states, the federal government, AARP, medical associations, privacy groups, and the New England Journal of Medicine have filed briefs in support of the Vermont statute, according to a brief by Cornell (N.Y.) University Law SchoolThe National Association of Chain Drug Stores, the Association of National Advertisers, the Associated Press, and Bloomberg have filed in support of the data mining firms.

In an age in which personal data can mined through social networks and search engines, this case could set the precedent concerning how much personal information can be used for marketing. A decision is expected by June.

 Tell us what you think. 

–Frances Correa (@FMCReporting on Twitter)

Leave a comment

Filed under Allergy and Immunology, Cardiovascular Medicine, Clinical Psychiatry News, Dermatology, Drug And Device Safety, Emergency Medicine, Endocrinology, Diabetes, and Metabolism, Family Medicine, Gastroenterology, Genomic medicine, Geriatric Medicine, Health Policy, Hematology, Hospice and Palliative Care, Hospital and Critical Care Medicine, IMNG, Infectious Diseases, Internal Medicine, Internal Medicine News, Medical Genetics, Nephrology, Neurology and Neurological Surgery, Nuclear Medicine, Obstetrics and Gynecology, Oncology, Ophthalmology, Orthopedic Surgery, Otolaryngology, Pathology, Pediatrics, Physical Medicine and Rehabilitation, Physician Reimbursement, Plastic Surgery, Practice Trends, Primary care, Psychiatry, Pulmonary Diseases and Sleep Medicine, Radiology, Rheumatology, Sports Medicine, Surgery, Thoracic Surgery, Transplant Medicine and Surgery, Uncategorized, Urology

A Doctor’s Best Friend

There was a wonderful article in The Wall Street Journal this week (with video) about doctors who routinely bring their dogs to their offices. The doctors say that the presence of a dog in a doctor’s office often helps patients open up or calm down, as needed.

courtesy of flickr user JohnONolan (creative commons)

Most of the doctors in the story are psychiatrists, who apparently have a history of bringing their pets to work. According to the article, Sigmund Freud often kept his dog (a chow named Jofi) in his office during patient visits, and he observed that the dog had a calming effect on his patients. Several of the contemporary psychiatrists reported similar observations. The dog’s temperament, rather than breed, is what matters. “Canine assistants” described in the article included a shih tzu, a Labrador retriever, cavalier King Charles spaniels, and mutts.

Obviously, some patients who are allergic to or afraid of dogs won’t get any benefit from having them around. So doctors who are considering bringing their pets on staff should warn patients in advance that a dog is present, and keep Fido out of the room as necessary. Dogs don’t have to be certified therapy dogs to help patients relax, but they should be reliably well-behaved. Doctors in other specialties, such as dermatology and plastic surgery, have been known to let their dogs have the run of the waiting room as a way to relax and entertain patients, although treatment rooms are off-limits.

The dogs seem especially valuable for the youngest and oldest patients. One of the doctors in the story, a neurologist who specializes in memory disorders, said that her two dogs put many of her older patients at ease. And one parent said her child actually looks forward to visiting her child psychologist because she loves seeing the dogs.

Having a canine staff member is budget-friendly, too. Dogs don’t need a benefits plan, and they take payment in snacks, walks, and love.

Happy Holidays!

–Heidi Splete (@hsplete on twitter)

Leave a comment

Filed under Dermatology, Family Medicine, IMNG, Plastic Surgery

A Little Mohs Respect

The Mohs technician – a non-physician (often even a non-healthcare worker) – occupies a unique place in the medical pantheon.

The Mohs surgeon’s right hand must be as steady as the surgeon’s own, capable of working with the most minute wafers of tissue, just a cell or two thick. A natural tinkerer who can adjust a highly complicated machine whenever its temperamental temperament gets out of whack. A perfectionist whose urge for the precision can never be shaken by deadlines, fussy patients, or cranky docs who just want to get out of here already.

At a Mohs surgery training course, sponsored by the American Society of Mohs Surgeons,  I learned first-hand (no pun intended) about what the tech brings to this fascinating area of surgery.

Alexander Lutz, the owner of Travel Tech Mohs Services, Inc., Carson, Calif., put it well during his talk on the issue: “It’s a rare relationship between and physician and non-physician, even more so than a surgeon with his surgical nurse or tech. The nurse might be helping the surgeon, but you aren’t depending on them to complete the surgery. With a Mohs technician, you are.”

A physician who wants to learn Mohs surgery can choose to hire and train a formally educated lab tech or histotechnician – or pick a staff person to train. It can be a nurse or medical assistant, or even the office manager. 

Knitting could be a sign of tech talent.

Photo courtesy Loggie-log/Wikimedia Commons

Mr. Lutz gave some pointers on picking the right trainee. Two characteristics are key: manual dexterity and a perfectionist personality. “In my experience, good Mohs techs have these things in common. I always ask if they have a hobby that shows dexterity-like knitting, musical instruments, or even juggling.”

And though the perfectionist personality part might drive the doc nuts in a personal relationship, it  will serve both well in the surgical suite. The success of Mohs surgery – and even the life of a human being – depends on those beautiful clear margins. The surgeon can only create those margins if there are plenty of beautiful slides to guide the surgery. And only a dedicated, skilled technician can make those beautiful slides.

— Michele G. Sullivan (on Twitter @MGSullivan)

1 Comment

Filed under Dermatology, Family Medicine, Geriatric Medicine, IMNG, Internal Medicine, Oncology, Pathology, Plastic Surgery, Primary care, Surgery, The Mole, Uncategorized

Hysterectomy Disconnect

At least two-thirds of hysterectomies in the United States are still performed through an abdominal incision, despite the availability of minimally invasive approaches that are associated with less pain, shorter hospital stay, more rapid recovery, and better cosmesis. In an attempt to change that, the AAGL  Advancing Minimally Invasive Gynecology Worldwide has just issued a position statement calling for nearly all hysterectomies that are done for benign uterine disease to be performed vaginally or laparoscopically, rather than abdominally.

"TAH" stands for Total Abdominal Hysterectomy. Image courtesy of Intuitive Surgical Inc.

According to the AAGL, the few contraindications to laparoscopic hysterectomy (LH) include conditions in which the risks of general anesthesia or intraperitoneal pressure are deemed unacceptable or where uterine malignancy is suspected. For both LH and vaginal hysterectomy (VH), exceptions include situations where trained surgeons or required facilities are unavailable, or in certain cases of distorted anatomy.

Otherwise, AAGL said, “When hysterectomy is necessary, the demonstrated safety, efficacy, and cost-effectiveness of VH and LH mandate that they be the procedures of choice.” 

So why aren’t they?  After all, in some European countries the rate of abdominal hysterectomy (AH) is less than 25%.  Interesting insight can be found in the results of a recently published online/paper survey sent to a random sample of 1,500 practicing U.S. obstetrician-gynecologists.

Among the 376 who responded, the most commonly performed hysterectomy procedure in the previous year was AH (by 84% of respondents), followed by VH (76%).  But when asked to rank which hysterectomy approach they would prefer for themselves or their partner, 56% ranked VH as their first choice and 41% ranked LH as their first choice, with only 8% opting for AH. 

When asked about barriers to performing minimally invasive procedures, the most common ones reported for VH included technical difficulty, potential for complications, and personal caseload. For LH, respondents cited lack of training during residency, technical difficulty, personal surgical experience, and operating time as barriers. 

Nonetheless, when asked about their ideal goal for mode of access, the respondents felt on average that minimally invasive techniques should comprise 79% of all hysterectomy procedures. 

According to the AAGL’s position statement, “Surgeons without the requisite training and skills required for the safe performance of VH or LH should enlist the aid of colleagues who do, or should refer patients requiring hysterectomy to such individuals for their surgical care.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

Leave a comment

Filed under Anesthesia and Analgesia, Family Medicine, Geriatric Medicine, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Obstetrics and Gynecology, Plastic Surgery, Practice Trends, Surgery, Uncategorized

Front and Center: Injectables and the Nose

It’s right smack in the middle of the face, but somehow, until now, I had not even considered injectables could be used to enhance the appearance of the nose.

Botulinum toxin for wrinkles on the forehead – seen it. Use of fillers to smooth out facial lines – I’ve watched these techniques live at dermatology meetings. Lip enhancement – I’ve heard a lot said about that too. But recontouring the nose? Nope.

“We are not going to replace rhinoplasty, but there is a lot we can do with fillers in an in-and-out procedure,” said Dr.

Dr. Vince Bertucci (left) and Dr. Jean-Francois Tremblay (photo by D. McNamara)

Dr. Vince Bertucci, a private practice dermatologist and cosmetic skin surgeon in Woodbridge, Ont., Canada. Making the bridge of the nose more prominent, relaxing the “bunny lines” a patient gets when they smile, and making a nose less “droopy” at the tip are examples.

Nonsurgical rhinoplasty has its advantages, Dr. Jean-Francois Tremblay said. Injectables “can be used to see if a patient likes the changes to their nose before making the changes permanent.” And, although results are not as dramatic, they avoid the often significant downtime, swelling, and pain associated with a traditional “nose job,” said Dr. Tremblay, a dermatologic surgeon in Outremont, Que., Canada.

Filler and/or botulinum toxin enhancements are less expensive. Also, unlike surgery, many filler corrections can be reversed or modified, Dr. Tremblay added. On the downside, the effects don’t last forever. Also, “you can only add volume and not remove anything.”

Many patients unhappy with their nose appearance do not know injectables are an option, commented a dermatologic surgeon attending this session at the ASDS/ASCDAS joint annual meeting in Chicago. Dr. Tremblay agreed, and said more patient education is needed in this area.

Dr. Bertucci receives honoraria from Allergan is a consultant for Procter & Gamble. Dr. Tremblay is a medical consultant for Allergan, Medicis, Canderm Pharma, LaRoche-Posay, Procter & Gamble, and Johnson & Johnson.

–Damian McNamara

@MedReporter on twitter.com

Leave a comment

Filed under Dermatology, IMNG, Plastic Surgery, The Mole, Uncategorized

When Good Fillers Go Bad

From the annual meeting of the American Society for Aesthetic Plastic Surgery in Washington, DC.

While intra-arterial embolization during filler injection is rare, it can happen to even the most experienced physician, said Dr. Claudio DeLorenzi. And it’s a good idea to have an embolization crash cart ready just in case.

Intra-arterial embolization can occur when a syringe full of filler accidentally enters a vessel. The filler can spread to affect vasculature beyond the injection site, and the results can be disastrous. Think skin necrosis, said Dr. DeLorenzi, a plastic surgeon practicing in Ontario, Canada.

The most immediate sign of intra-arterial embolization is severe pain. A crash cart for this complication can allow you to respond immediately. The cart should contain hyaluronidase—which can reverse the effects of HLA fillers—aspirin, nitroglycerine paste, and heat compresses.

Of course, prevention is always preferable. Dr. DeLorenzi recommends using a blunt cannula, working slowly with low pressure, and knowing the relevant anatomy. It is also a good idea to work with small amounts of filler—less than 0.1 cc.

“The most severe cases that have been reported have one thing in common. … A lot of material was injected into one single spot. That single spot happened to be inside a blood vessel,” Dr. DeLorenzi said in an interview.

This post originally appeared on The Mole, the blog of Skin & Allergy News.

—Kerri Wachter ( @knwachter on Twitter)

Bookmark and Share

1 Comment

Filed under Dermatology, IMNG, Plastic Surgery, The Mole

Reflections of a Laser Pioneer

Dr. Charles Townes

From the annual meeting of the American Society for Laser Medicine and Surgery

It turns out that the man credited with the invention of the laser as we know it today had no intentions of the using the device in medicine. “I didn’t foresee that,” confessed Dr. Charles H. Townes, who in 1954 first demonstrated the use of what became the laser. Only then it was called “maser,” an acronym for microwave amplification by stimulated emission of radiation. “But I could foresee a lot of applications which I knew where there. My primary objective was scientific,” he said. “I wanted a new tool to do high resolution spectroscopy.” 

Dr. Townes, currently a professor of physics at the University of California, Berkeley, went on to publish the theoretical principles of the laser and in 1964 earned the Nobel Prize in physics for the achievement. On hand to be honored by the ASLMS for his lifetime work in the field of laser research, the 94-year-old Dr. Townes told meeting attendees that some of his scientific peers in the 1950s doubted that he’d be able to put his ideas into practice, considering him “stupid and wrong.”

How wrong they were. 

–Doug Brunk (on Twitter@dougbrunk)

Leave a comment

Filed under Drug And Device Safety, Family Medicine, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Plastic Surgery, Surgery