An autopsy has confirmed that the South Florida teenager, Stephanie Kuleba, who died this Spring after corrective breast surgery (reportedly for significant asymmetry and inverted nipples) suffered from a rare genetic disease that had been speculated to have causes her death. Genetic testing at the University of Pittsburgh shows she possessed the genetic mutation RYR-1 which is responsible for most cases of the malignant hyperthermia (MH) response to certain inhaled anesthetics. However, over 80 genetic defects have now been potentially associated with MH. As these mutations are inheritable, they will vary in rates among the population and some increased clusters of MH mutation carriers have been suggested in states like Wisconsin, Nebraska, West Virginia and Michigan.

The exact incidence of Malignant hyperthermia is unknown, but the rate of occurrence has been estimated to be as frequent as one in 10,000 or as rare as one in 100,000 patients who undergo general anesthesia. (A range that big suggests they have no idea to me) There is no practical screening test to determine if a patient has the rare condition so you rely on family history or consultation questions to identify high risk patients. Again, the incidence is so rare there is no way to prevent these MH events from happening. The signs that develop are usually suble (ie. a tense jaw) before they're not (ie. 104 degree temp and cadiovasular collapse).


Despite her doctors efforts to treat the Ms. Kuleba during the event with the medication Dantrolene, her parents claim her Plastic Surgeon's office was not prepared to care for their daughter once they had figured out that she was suffering from the hidden hereditary condition and have (in the great American tradition) announced their intention to file a lawsuit.

When MH is identified or suspected, time becomes valuable for salvage treatment. As soon as the malignant hyperthermia reaction is recognized, all anesthetic agents are discontinued and the administration of 100% oxygen is recommended. Dantrolene should be administered by continuous rapid IV "push" beginning at a minimum dose of 1 mg/kg, and continuing until symptoms resolve or the maximum cumulative dose of 10 mg/kg has been reached.

Kulebas' family attorney Roberto Stanziale, has said the teenager should have received as many as seven vials of the drug as an initial dose. On medical records Stanziale obtained following her death, one doctor noted she received one vial of the antidote. The other doctor wrote she received two. It's not known at what time the drug was administered or whether there was enough Dantrolene available at Dr. Schuster's Boca Raton clinic, Schuster Plastic Surgery. Both doctors have defended their actions, saying the situation was handled appropriately and that Kuleba received the Dantrolene dose needed once they consulted with the Malignant Hyperthermia Association (MHA) hotline and called an expert at the Mayo Clinic in Minnesota.

This dosing issue and it's timing is going to be a big issue in the lawsuit. You can't really give informed consent for MH as it's so rare so that shouldn't be an issue (although that will likely be claimed by a plaintiff's attorney). According to the brochure for Dantrolene, each vial contains 20 mg of the drug. As it's suggested in her anesthesiologists notes, she received 2 vials initially (40mg) while they called the MHA hotline to confirm treatment (as again it's so rare no one really has a lot of experience with treating it). That 40mg dose is in the ballpark for the recommended range (by weight) for initial treatment for most thin teenagers.

At the end of the day, I'm not sure what's going to be achieved with this lawsuit. It sure seems like reasonable steps were initiated by her doctors after the event to try and save this girls life. There is only so much you can do when unforeseen or extremely rare complications arise and no amount of preparation can prevent some bad outcomes. Contrast the hostile posture of the Kuleba family attorney with this MH tragic event during orthopedic surgery on a 20 year old described by Dr. Henry Rosenberg, President of the Malignant Hyperthermia Association of the United States. The pain of the medical staff and their communion with the deceased's family is moving.

I hope that this event will continue to foster more discussion on oversight for office-based surgery and anesthesia. It's ironic that it's actually been Plastic Surgery that been the most progressive in regulatory oversite in ambulatory surgery. While this case was an anesthesia complication rather then a surgical one, the who's, where's , and how's of who can (or should) be doing surgery is overdue for more scrutiny.


Rob

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In October I wrote about spatial perception and the concept of being left or right brained as it applied to your surgeon. While generalities about artistic taste or surgical ability being associated with left/right dominant brained people and the like as it applies to individuals is a silly idea, I definitely think the ability to understand and intuit spatial relations is important.

Much like a pool hustler understands the geometry and physics of a bank shot without getting a compass and calculating force vectors, surgeons process symmetry, proportion, and volumetric relationships. With laparoscopic surgical techniques utilizing small cameras and long, remote instruments there are several studies suggesting that people who are good at video games tend to be better at laparoscopy. Researchers found that surgeons who spent at least three hours a week playing video games made about 37 percent fewer mistakes in laparoscopic surgery and performed the task 27 percent faster than their counterparts who did not play video games.

I think I've discovered a great video-game proxy for Surgery. Valve Software published the title PORTAL this Fall as a under-publicized throw-in for their blockbuster video game, Half-Life 2. Portal is a unique puzzle game that is a real mind-bender in the way you have to understand spatial relations, momentum, physics, and inertia. It is also a really, really creepy experience in artificial intelligence (AI) paranoia. The phrase in the title of this post, "The cake is a lie....", is a critical plot device in the story. You can read plot spoilers on Wikipedia's Portal Page.

So next time you go to surgery, forget those questions about their experience, training, or board certification. Rather, find out how good they are at Portal :)

Portal's trailer is visible below via YouTube.




Rob

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In this month's Plastic & Reconstructive Surgery, our profession's flagship journal, there's a study about the symptomatic relief woman receive after breast reduction who fall below the minimum threshold insurers require for coverage. To no one's surprise, even reductions less then half of the average weight removed showed dramatic symptomatic improvement at over 1 year out from surgery.

Most health insurance plans require a minimum of 500 gm (~ 1.1 lbs) of tissue to be removed per side for coverage in addition to documentation of symptoms related to their breast size. Occasionally you get some asinine form letter asking for proof of "conservative" treatment of large breasts prior to surgery, whatever the hell that is!

The authors of this study call for review by insurers of their criteria for coverage. Good luck! Insurers haven't been recording record profits by dramatically expanding their potential exposure for surgical procedures. This study doesn't really offer much that hasn't been presented to these companies for years. They're not interested in the close to three dozen papers with similar findings in the published literature.

The catch-22 here is that when coverage is expanded usually the reimbursement for the surgeon is cut. Breast reductions are long and physically hard procedures which can take 3-4 hours when you do it by yourself on large reductions. What we get paid for these is about 20-30% of what is commanded for mastopexy (breast lift) surgery, a closely related procedure which often may involve a small reduction component. It's gotten to the point for many surgeons that they just won't do it anymore as (depending upon the insurer) these hover right at the break even point for their practice when all the costs and follow-up care are figured. If you don't believe me, try finding a list of providers who will accept Medicaid assignment for these.

Rob

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At least a few times weekly I get asked whether or not someone will have a scar after a certain procedure. People are sometimes under misconceptions about how exactly Plastic Surgery works. Anything you cut, burn, or excise scars. The quality depends upon a number of factors including

1. location - certain areas don't scar as well as others (behind the ear, the medial-lower breast, the armpit, the scalp)



2. tension - more tension equals wider scars. This plays a factor in the areas listed under location. Incisions across areas with lots of motion (the knee, wrist, & shoulder) all tend to be wide.



3. technique - Plastic Surgeons didn't invent good surgical technique and gentle tissue handling habits, but we tend to pay more attention to it.



4. genetic predisposition - sometimes it's your parent's fault. A number of people display profound inflammatory responses with exaggerated scarring from anything. I make a point of discussing this with Asian and African-American women (who have higher rates of hypertrophic or keloid scarring) when discussing breast surgery.



5. medical commodities - diabetics, obese patients, those with arterial disease, and gastric bypass patients all have baseline wound healing problems to some degree.



6. age - the inflammatory response of normal healing varies with age. You can do experimental surgery in utero and get essentially scarless healing of a fetus. However the response in children and teens to injury can be exaggerated scars as their immune systems tend to be "peaking" during those years. Alternatively, you can do things to the face of 70-90 year olds that would disfigure younger patients and often not even find a scar.

Rob

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There's an article on MSN.com today "Way to go, grad! Here's a check for a new nose - Is cosmetic surgery an appropriate commencement gift for teens?" that's kind of interesting. It's a brief synopsis over the increasing trickle-down of Plastic Surgery procedures to teens which ballooned to 244,000+ procedures in 2006 (data form the Amer. Society of Plastic Surgeons (ASPS)), including about 47,000 nose jobs and 9,000 breast augmentations. The discussion mostly centers around teenage girls and breast surgery. The few teenage boys you see in a Plastic Surgeon's office usually have gynecomastia (excess male breast tissue).

The story of one of the the teens featured caught my eye,

When Courtney Powers graduated from high school last year, she didn’t receive a new computer or a trip to Europe. The North Carolina teen got a pair of D-cup breast implants.

“My breasts hadn’t grown since I was 16,” says Powers, who underwent cosmetic surgery two days after her 18th birthday. “I was a 36AA and my mom and dad knew I was very self-conscious.”

Not to beat a dead horse, but in general, I'd consider the implant size (425-500+ cc) required to go from an A-cup to a D-cup to be a very,very poor choice for long term results in most women. Larger implants are both heavier and wider which dramatically accelerate "aging" of the breast tissue and skin. Ms. Powers' native horizontal and vertical boundaries and tissue attachments likely had to be violated to accommodate her implants, which is something best avoided when you can help it. Avoiding over-sized implants (particularly saline, as they're heavier) is the single most-effective thing you can do in breast surgery to minimize reoperation rates. Last year the perceived problem breast augmentation in teens by a prudish politician caused a mild political controversy in Australia, which I touched upon here.

Issues about the propriety of doing surgery on adolescents or young adults come up a good deal in our field as almost all these procedures are elective rather then absolutely necessary. It's a little patronizing to make blanket statements about older teens like Ms. Powers, as many of them are old enough to vote, marry, or serve in the military. With younger teens it becomes something to consider on an individual basis and becomes invested with a lot of gray area.

Is it appropriate to do teen surgery for breast reductions or reconstruction of congenital breast deformities (which often require implants)? Many feminists who decry cosmetic surgery in teens (or adults) would probably make exceptions for those patients despite the fact that those operations are often cosmetic (rather then functional). The ASPS position paper on elective breast surgery and other procedures recommends using 18 years old as a relative (but not absolute) guide for practice guidelines.

There's a little of the PC sentiment about inner beauty proffered in the article on MSN by Courtney Macavinta, author of “Respect: A Girl’s Guide to Getting Respect and Dealing When Your Line Is Crossed.”

"By giving teen girls, in particular, surgery we’re just sending this message to them that they can be anything they want to be — they can go to any school or do anything in life — as long as they look a certain way on the outside.

I’m all for taking a shower, combing your hair and getting a cute outfit, but there is only a tiny percentage of people whose profession and success rely on appearance,” says Macavinta. “The girls who thrive and prosper in life very quickly invest their energy other places — like their brains, compassion and humor."

This is quickly squashed with a cold,hard dose of reality by Dr. David Sarwer, Associate Professor of Psychiatry at the Hospital of the University of Pennsylvania, and probably the world's authority on issues of body image and psychological outcomes in Plastic Surgery

“From a societal perspective, the reality is that whether we like it or not, our appearance does seem to matter.Studies show that attractive people are treated more favorably and that a positive body image can account for up to one-third of self-esteem....Body image improves after surgery. Self-esteem and quality of life can improve as well. However, more studies are needed before we can say that kids benefit the same way adults do.” "

Rob Oliver Jr. MD

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An Orlando,Florida radio station's contest offering a free breast implant is drawing controversy over both the contest and the "surgeon" who will be performing the operation. Real Radio 104.1 is offering the breast augmentation to the woman who parties during a so-called slumber party. The rules: Spend 30 hours with radio personality Tiffany (click for NSFW gallery) in front of a camera broadcast live on the Internet. The station website says "the girl that parties the hardest" wins.

An article from the news outlet Florida Today is available titled "Breast implant contest doc on probation"

The man chosen to perform the surgery, an osteopathic doctor with a licence under probation.



Now what specialty do you think the doctor is??

He's a Plastic Surgeon of course, right? No

Well, ok... at least he's a Surgeon then? No

Is he at least a MD? ....Well apparently he underwent an osteopathic residency in emergency medicine in Ohio twenty years ago. Does that sound kosher enough for you?

What you have here is another example of a non Plastic Surgeon (who I repeat is not even a trained surgeon)who promotes his expertise in way that makes it hard for patients to figure out exactly what he is. Like many of the fringe group of specialties trying to reinvent themselves as cosmetic surgeons, he performs office surgery while (according to the Florida Medical board website) holding no hospital privileges to perform surgery.

This "loophole" is something that has been discussed, where in the future you may actually be required to have similar credentials in a hospital to do surgical procedures in your office. This makes too much sense not to be widely embraced, that I'm sure it never happen. Rules re. how you can advertise your credentials in print or in advertising are also starting to pop up which would hopefully kill off the cottage industry of "board certifications" by organizations of dubious quality. See this blog entry I did last year "Who's a Plastic Surgeon (and who is not)"

Now this ER doctor may in fact be both a nice guy and a capable doctor, but it is inconceivable from available information in the Florida Department of Health practitioner database that he should be performing procedures this far out of the scope of practice of his accredited medical training in emergency medicine.

The radio station seems somewhat unapologetic about the controversy saying

"We got a contest going on in two days that I thought would get more attention, we are doing 'Fatties at the Fair' (tasteful!) where we send big women to the Central Florida Fair where they ride rides and eat food all day. I thought that would get more attention than this. Obviously, when you are in radio, you do whatever you can to get attention but you don't want anybody to actually get hurt or anything to happen. Nothing bad is going to happen to our listeners. We love the Monster fans."

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On this day April 16,1992 the FDA started the groundwork for what would ultimately be the reintroduction of silicone gel breast implants (SBI) when they relaxed the outright prohibition that had been hastily introduced shortly before and started some of the early clinical trials that would provide data for further review.

It was nearly 15 years later this past October when they finally (officially) concluded that they were likely mistaken and reintroduced SBI's. We're now part of the international consensus of over 60 countries where this has been the decision by the respective health regulatory agencies overseeing this in other countries.

I found this January 1992 editorial from Reason Magazine (click to read) which is an interesting window into the mindset and arguments flying around at that time. Many of the philosophical issues are the same now as then. It's interesting that the author of this was spot on in warning that (at that time) pending epidemiological studies might not corroberate the claims being asserted in lawsuits. Since then an avalanche of literature has done just that.

In its letter to the Food and Drug Administration requesting a ban on the implants, the advocacy group Public Citizen repeatedly emphasized the frivolous nature of cosmetic surgery: "Because approximately 80 percent of these devices have been used for breast augmentation, as opposed to reconstructive purposes, the overwhelming 'public need,' not the public health need, for these devices is the psychological benefit of having more perfect or larger breasts . . . . We do not accept that the psychological needs of women, who seek breast augmentation, are legitimate public health needs within the meaning of the {Food, Drug and Cosmetic} Act."

The notion that breast augmentation is simply wrong undergirds much of the hostility to the procedure. In her widely discussed book, "The Beauty Myth," Naomi Wolf characterizes breast augmentation as "sexual mutilation." And Public Citizen declares in a press release, "The widespread use of silicone gel implants for surgery that is purely cosmetic is a particularly egregious aspect of the issue."

Take the claim that silicone breast implants cause scleroderma, a connective-tissue disorder that leads to a painful tightening of the skin. To lead in to its program on the implant controversy, "Nightline" featured a woman who had had a breast implant and who had later developed scleroderma. Reporter Judy Muller told viewers that the woman's doctor "believes the disease was caused by silicone leaking from the breast implants."

Muller did not inform viewers that there is no epidemiological evidence to back up that diagnosis. To tell whether there is indeed a connection between implants and scleroderma-like disorders would require a large sample of women who had received implants, whose medical histories were well-documented and whose symptoms were unambiguous. Such evidence may be forthcoming, although a May 1991 literature search under the auspices of the American Medical Association turned up only 28 women who had developed connective-tissue disorders after receiving silicone gel implants. For now, it is scientifically incorrect to say that implants cause such auto-immune diseases.

To such arguments, implant opponents reply by pointing to scleroderma victims. See, they say, it happened to this woman. She had an implant and now she has a disease. Post hoc, ergo propter hoc. The statistical standards of proof on which epidemiologists rely do not make for powerful journalism. And they run counter to the case-oriented culture of clinical practice.

In evaluating the safety of breast implants, the FDA and the courts should view the evidence rationally, with an eye toward real epidemiological proof rather than emotional claims. Regulators should seek to inform women of risks, not deprive them of choices. And those women who do want the freedom to make informed choices must take responsibility for the consequences, rather than going to court later to demand compensation for bad outcomes. Above all, the FDA should avoid taking refuge in extremist, paternalistic views of what women should be and what women should want.

A couple of other Reason Magazine articles about breast implants can be read here, here, and here

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Found a thought-provoking editorial in The American magazine, titled "Second Thoughts on Breasts." which summarizes some of the history of regulatory issues with silicone implants. The effects of this on the corporation and employees of Dow Corning(which was sued out of existence)are touched upon nicely. It's ironic that if Dow had waited about 15 months (when the first of the large studies not finding links between silicone and disease was published by the Mayo Clinic) they would have not had to pay a dime of the multi-multi billion dollar settlement.

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Neat video clip story about a women who suffered a penetrating chest wound while sport fishing for marlin. Her treating physician speculates that her indwelling silicone implants (which were ruptured from the marlin bill) may have saved her life by blunting the force as she was stabbed. Apparently, serious penetrating injuries are not that rare from marlins as I found several recent reports (see here)

Another life saved by breast implants! :) As someone joked in re. to these stories last year about an Israeli woman saved from shrapnel and a car crash survival attributed to implants "Go big or die."

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This weekend is time of year for the Dallas Rhinoplasty Symposium, one of the bigger meetings in the Plastic Surgery calendar. Dallas has been one of the more influential cities for many years in Plastic Surgery due to some of the contributions of local Plastic Surgeons and it's become one of those places we (surgeons)immediately associate in our heads with nasal surgery. The work, teachings, and prolific writings from Dallas doctors Jack Gunter, Rod Rohrich, and others has really defined what rhinoplasty surgery is in 2007.

Besides Dallas with noses, there are a few other American cities that have such strong association with certain procedures which have to do with historical contributions to Plastic Surgery.

Manhattan - the spiritual home of the facelift and decades of influential craniofacial surgeons like Marquis Converse (former head of NYU Plastic Surgery division)

Atlanta - where breast surgery will always be synonymous due to the developments in breast reconstruction techniques (TRAM flaps, latissimus flaps) and the teachings and textbooks of the late John Bostwick MD (former chief of Plastic Surgery at Emory University)

Louisville (KY) - the Kleinert Clinic is the world's largest hand and microsurgery practice and has trained hundreds of American and international surgeons. Dr. Harold Kleinert, was a pioneer in the field and developed a super-tertiary group practice around his expertise that attracts patients from all over the world. When you think of hand surgery, you think of Louisville. Which is ironic as I trained there at the University and over at the Kleinert Institute and I don't do any hand or microsurgery to speak of - Rob

There are a lot of famous surgeons scattered in locations across the US, but I don't think any of those cities have such singular connotations with specific procedures. Please feel free to leave suggestions in the comments!

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