Friday, February 27, 2009

The most underrated dermal filler - Radiesse

Quick thought of the day on practical matters....

I continue to be impressed with the dermal filler, Radiesse. It's nowhere near as popular as the Hyaluronic Acid fillers (like Juvederm and Restylane), but it has some very useful properties.

Radiesse is made of calcium-based "microspheres" suspended in a water-based carrier gel. The gel degrades after injection, but the calcium spheres persist and cause an inflammation that stimulates collagen deposition.
Results like below (which I found on the net)are pretty striking when you direct this product into the cheek and deep nasolabial folds and "marionette lines" under the mouth.

Why do I like this so much? In two words, it's effective and efficient. One syringe of Radiesse is worth the effect of 2 of the hyaluronic acid fillers syringes and lasts up to two years to boot! In general, I think this is a much better deal for most patients even though it probably generates less revenue for me because patients don't need as many injections (due to the length of duration).


Sunday, February 22, 2009

Game Show Bloopers!

A break from heavy things today.

This collection of game show bloopers is really funny!


Wednesday, February 18, 2009

Usher's wife update on anesthesia complication

Information about the emergency Usher's wife underwent in Brazil recently came to light. Two months after giving birth to the couple's second son, Raymond, 38, traveled to Brazil to have liposuction on her stomach by São Paulo plastic surgeon Dr. Silvio Sterman.According to the doctor involved, Tameka Raymond went into "cardiac arrest" while being anesthetized before a liposuction procedure. She was quickly revived and then placed in an induced coma(?) for 24 hours as a precaution and apparently remains in stable condition in a Sao Palo hospital. The news wire is reporting that she was discharged today and will be returning stateside shortly.

Ellen Dastry, spokeswoman for plastic surgeon Silvio Sterman, says Tameka Raymond checked into the Sao Rafael Hospital last Friday for a "simple liposuction." Dastry said that Raymond suffered a cardiac arrest while being anesthetized for the procedure "but was revived in less than a minute by heart massage." She was then placed in an induced coma before being taken to the intensive-care unit, a procedure Dastry said was "absolutely normal" and performed in order to "avoid unnecessary complications."

I'm a little confused about what may have happened here. It doesn't sound like she had a malignant hyperthermia (see related post here) reaction, but I can't figure out the rationale for the "induced coma". That would not be a normal treatment for a heart attack or lethal arrhythmia (irregular heartbeat), but could be present with malignant hyperthermia.

In a brief search for some consensus in the anesthesia literature on this I found some reference in a recent text which wrote

"Postpartum concerns include a decreased blood hemoglobin and the increased risk of pulmonary aspiration. Anemia is almost always present as a result of physiologic anemia of pregnancy combined with blood loss during and following delivery"

That's pretty tangential to this case, but it's all I can find with superficial snooping. Now liposuction after childbirth would not be expected to be a particularly bloody procedure, it is still something to consider.

More important would be questioning the logic of doing liposuction that early after pregnancy. I'd submit it would be someone with poor judgment who would proceed with that surgery on a practical basis. Good results with lipo rely upon contraction of the skin after it's debulked. There a are a number of circulating hormones associated with pregnancy that predispose tissue to expand to accommodate the developing embryo. Those mediators have clearly not normalized at only two months, and the patient has not reached a plateau in terms of her weight or abdominal wall tone at that point. Pro ceding with surgery is likely to not achieve the expected results in most instances. When would be a "normal" recommendation to proceed in the short term? Think closer to 9-12 months post delivery.

Of note, the NY Daily news is reporting that that the patient may have not been truthful with her surgeon about how far post partum she was. Evan a few months may have been the difference in her being deemed fit for surgery in this instance.

So what else could have happened?

Well, as the fluid used to perform liposuction has adrenaline and local anesthetic solution in it, a large intravascular bolus of this could precipitate a heart arrhythmia or event. Dilated veins in the postpartum abdominal wall may be more likely "targets" to be inadvertently speared by the infusion cannula used to put fluid in to tumesce the tissues for liposuction.

Just a thought!


Wednesday, February 11, 2009

News of the day - Fall in the house of Usher - Usher's wife's surgery complication, vitamins, and the failure of preventive care model

A couple of things on my radar today

1) Hitting the news wire today is the report that R&B singer, Usher's wife has had serious complications from cosmetic surgery performed in Brazil. This procedure was also performed only two months after childbirth, something that raise eyebrows in re. to timing any major procedure on the breast or body. I guarantee the first thought that most Plastic Surgeons are going to have is that "Why would you fly to South America for surgery when you have the money to see anyone in the United States?".

It is absolutely a poor decision to do something like elective surgery half a world away from your doctor's and family. While there are truly some magnificent surgeons in Latin America, you introduce a lot of potential logistical issues when there are complications. In this instance, they've apparently flown a doctor down there to oversee treatment (as I'm presuming they were uncomfortable with the local care). That alone speaks volumes as to why this is a bad idea. The low cost cosmetic surgery "chop shops" that exists right over the border in Mexico are notorious for having complications and dumping patients stateside for treatment.

2) In the latest of a series of large studies (click here) assessing the effects of vitamin supplements, we once again see NO demonstrable benefit in a daily multivitamin. This follows on the heals of similar studies (with similar findings) on vitamins A, C, and E. It once again confirms "Rob's Rule" that you cannot outsmart mother nature.

3) The Chicago Tribune points out that an "ambitious effort to cut costs and keep aging, sick Medicare patients out of the hospital mostly didn't work," according to a study published in this week's Journal of the American Medical Association (JAMA). Any doctor, nurse, medical student, or even janitor who works in a hospital could have told you that minus the hundreds of man hours spent performing that study. In a corollary to "Rob's Rule" on mother nature, I might add that in general you don't save any money with preventive health care, you just redistribute it in other directions (and may in fact end up costing even more, it's counter intuituve, I Know!).

It would be nice if President Obama, et al. would be willing to admit that any steps they do that are "painless" to patient choice or patient care (ie. preventive care, the "medical home", or the electronic medical record (EMR)) will not save one dime on health care costs. Those choices that will affect cost have winners and (big) losers and will be extremely polarizing. Barack Obama does not want to be campaigning for reelection in Florida in 2012 explaining why 75 year old grandma can't get her hip replaced because his actuarial based plans for health care spending suggest her quality of life is less valuable then someone in their 50's needing a total knee replacement.


Friday, February 06, 2009

Plastic Surgery Specialists - Our new office's grand opening!

Well we moved into our new office this week. Wow! What an incredible amount of logistics for a (relatively) small construction project. We're working on the office OR suite accreditation and hope to be doing cases by April on site.

For directions click here.

I continue to be incredulous over office surgery regulations (or thereof). It's amazing that a family practice doctor, OBGYN, or radiologist could go to a weekend course and start performing major cosmetic surgery in a un-inspected exam room without scrutiny or real oversight. My partner and I on the other hand, designed an OR suite that exceeds hospital standards and will require ongoing QA and inspections. To build, furnish, run, and accredit this is expensive (think hundreds of thousands of dollars) but worth it to provide a safe environment.

Once again, I call on states to address this area of office surgery more closely.