Blog — Notes of a Plastic Surgeon

Welcome to my blog. I am a plastic surgeon in Seattle and have been in private practice since 1991. I've seen more than a few interesting faces and cases through my years spent in the exam room, the operating room and the emergency room. And I have an opinion on just about everything relating to plastic surgery (and a lot of unrelated stuff). If you like my blog, let me know. Thanks for reading! Lisa

Category: Patient Safety


Should you travel for breast explant surgery ?????

August 29th, 2019 — 2:00pm

This post is based on a phone consultation from earlier this week.  I’ve changed a few unimportant details to protect patient privacy.

That bag is gonna be a killer to get into the overhead bin after surgery!

This lady has smooth, saline implants that are about 10 years old.  She is part of the Pacific Northwest Breast Implant Illness (BII) Facebook group and she thinks her implants are making her ill.  Her augmentation was done by the (IMHO) very best plastic surgeon in her state who lives and practices in the patient’s hometown.  She has seen her plastic surgeon for explant and her plastic surgeon has agreed to do her explant and remove as much capsule as can be safely done.  So why, I ask, does this patient want to come see me???  Am I an explant expert?   Well, sort of in that I have done about a bajillion explants (mostly reasons other than BII) over the 28+ years I’ve been in practice.

But……………….explant and capsulectomy is not specialized surgery.  This is a procedure that just about any plastic surgeon who does a lot of breast surgery is capable of doing.  Now, I would not expect, say, a craniofacial surgeon to have any great expertise (or interest) in this but most “general” plastic surgeons are very capable of doing this.  Promoting myself for explant and capsulectomy is sort of like Gordon Ramsey promoting himself as the ultimate chef for grilled cheese sandwiches.

So how about the fabulous explant experts who can guarantee an “en bloc” and offer “detox” products?  Well…………………………….I’m not gonna throw anyone whom I have never met under the bus.  But I will say this:  There is zero, nada, zilch, nichts, niet, nula, noll, odo evidence that an en bloc resection is absolutely necessary or that detox does anything other than slim down your bank account.  It’s super nice (and sort of fun) to do an en bloc in cases of silicone gel rupture but there is no evidence in peer reviewed surgical literature that there is any difference in clinical outcome.  The same goes for cases of BIA-ALCL.  Would I recommend a careless surgeon who is not thorough or does not endeavor to keep things as clean as possible?  Of course not but I must say the vast majority of plastic surgeons are pretty damn thorough and meticulous.  It’s in our DNA.

We plastic surgeons are always ragging on surgical tourism and espousing the danger of going to a distant land for el cheapo plastic surgery but we should also be ragging on traveling within the United States for routine procedures.  Travelling adds a lot of complexity to the whole surgical process from initial evaluation to final follow up.

There are plastic surgeons being promoted as some sort of super experts by the breast implant illness activists.  I have zero evidence that money is changing hands but isn’t it a little weird that this sisterhood, who should want what is best for other women, to recommend traveling hundreds and sometimes thousands of miles for a routine surgical procedure?  Oh, and waiting sometimes up to a year to have their toxic bags of death removed?  And as for detox?  Zero evidence of necessity or efficacy. You can get your detox package from your local woo woo health provider who is happy to lighten your wallet.

So think global, buy local and support your probably very capable local plastic surgeon!  Just make sure your plastic surgeon is the real meal deal and certified by the American Board of Plastic Surgery.

Thanks for reading and I would be thrilled if you followed me on Instagram @sowdermd and @breastimplantsanity.

Dr. Lisa Lynn Sowder

Breast Implant Illness, Breast Implant Removal, Breast Implants, My Plastic Surgery Philosophy, Patient Safety, Plastic Surgery

En Bloc Resection of Breast Implants and Capsules

April 2nd, 2019 — 9:20am

I get a lot of requests from breast implant illness patients to do an en bloc resection of their implants and the surrounding implant capsule.  The term en bloc refers to a procedure that removes the structure in question in one piece or all together.  This term is used most commonly in cancer surgery where a tumor is removed in its entirety without actually cutting into the tumor itself.  Except in cases of BIA-ALCL, implant capsules are not cancer.

The photo below shows an en bloc resection of two ruptured breast implants and the surrounding capsule.  In cases like this, doing an en bloc makes a lot of sense in that it prevents any spillage of silicone and makes for a much cleaner explant.  Fortunately it is cases like this where an en bloc is usually doable.  The thick, nasty and calcified capsule often just peels away from the adjacent breast tissue, muscle and chest wall without causing any collateral damage.  Doing a clean and slick case like this is what surgeons live for and believe me, I wish every explant would go just like this!

But……….it is not always possible to do an en bloc resection.   Sometimes the capsule is very, very thin and fragile (sort of like a wet Kleenex) and it is not possible remove it unbroken.  Sometimes the capsule is very adherent to adjacent structures such as breast tissue, ribs and chest muscle.  It is just not worth the damage to those normal structures to get an en bloc resection.  Sometimes, with implants under the muscle, the patient is at risk for a collapsed lung when trying to peel a very adherent capsule from the rib cage. In cases like this, the capsule can be removed with curettage.  And sometimes, with really large implants or those put in though the axilla (arm pit), the upper part of the capsule cannot be visualized with the implant in the way.  And if I cannot see it, I will not cut it.  In those cases, I remove the implant and then am able to safely remove the capsule.  I am very careful about minimizing or, in most cases, eliminating spillage of any leaking gel.bessss

 

I am aware that the breast implant illness community is obsessed with en bloc capsulectomy.  I’m not sure why because for clean, intact implants, there is no compelling reason to do an en bloc, except maybe to show off and promote oneself, and yes, I am guilty of that!   Many patients are lead to believe that there is some sort of evil humor or miasma that exists in the space between the intact and clean implant and capsule.  The space (which is actually what we call a potential space because it contains nothing) contains nothing!

It is really easy to pontificate for a potentially dangerous procedure when one has zero responsibility for any downside.  Who is responsible for harm to the patient – the surgeon holding the sharp instruments or the social media pundit?

And I am also aware that there are surgeons out there who guarantee an en bloc, every implant, every time.  I honesty don’t know how they can.  I also provide a guarantee… I’ll do my best.

Thanks for reading!  Dr. Lisa Lynn Sowder

I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

Breast Implant Illness, Breast Implant Removal, Breast Implants, Patient Safety, Plastic Surgery

Brazilian Butt Lift – A Dire Warning.

July 19th, 2018 — 9:29am
This is an email I received last week.  I want to share it here.  Please pass it along to anyone who may be considering a Brazilian Butt Lift:

Not worth dying for.

URGENT WARNING TO SURGEONS
PERFORMING FAT GRAFTING TO THE BUTTOCKS
(Brazilian Butt Lift or “BBL”)
This urgent advisory is in response to the alarming number of deaths still occurring from the Brazilian Butt Lift (BBL).The Multi-Society Task Force for Safety in Gluteal Fat Grafting (ASAPS, ASPS, ISAPS, IFATS, ISPRES), representing board-certified plastic surgeons around the world, recently released a practice advisory). Additionally, the Task Force is conducting anatomic studies to develop specific technical safety guidelines.Since the release of the practice advisory, deaths from this procedure continue to be reported. The unusually high mortality rate from this cosmetic procedure is estimated to be as high as 1:3000, greater than any other cosmetic surgery.

The cause of mortality is uniformly fatal fat embolism due to fat entering the venous circulation associated with injury to the gluteal veins. In every patient who has died, at autopsy, fat was seen within the gluteal muscle.

In no case of death has fat been found only in the subcutaneous plane.

The Task Force has therefore concluded that: FAT SHOULD NEVER BE PLACED IN THE MUSCLE. FAT SHOULD ONLY BE PLACED IN THE SUBCUTANEOUS TISSUE.

If the desired outcome might require another procedure, then manage the patient’s expectations and discuss the possibility of staging (as often done with fat injections, hair transplants, etc.)

IT IS EASY TO UNINTENTIONALLY ENTER THE MUSCLE DURING SUBCUTANEOUS INJECTION.

Therefore, stay mentally focused, alert, and aware of the cannula tip at every moment; be vigilant about following the intended trajectory with each stroke and feel the cannula tip through the skin. Consider positioning that can favor superficial approaches, such as table jackknife. Use cannulas that are resistant to bending during injection and recognize that Luer connectors can loosen and bend during surgery.

The risk of death should be discussed in your informed consent process, along with alternative procedures (such as gluteal implants or autologous flap augmentation).

No published series of BBLs done with intramuscular injections is large enough to demonstrate it can be done without the risk of fat embolism.

The subcutaneous plane has not been linked to pulmonary fat embolism. Until and unless data emerges that intramuscular injections can be done safely, the subcutaneous plane should remain the standard.

Fat injected into the subcutaneous space cannot cross the superficial gluteal fascia and migrate into the muscle; therefore, any intramuscular fat found at autopsy can be concluded to be the result of injection into the muscle.

Surgeons wishing to continue performing this procedure should strictly adhere to these guidelines. The Task Force is actively performing anatomic studies. and more specific technical guidelines will be forthcoming. We need to dramatically improve patient safety with this procedure through careful technique, or reconsider whether the procedure should still be offered. Patient safety is the number one goal of board certified plastic surgeons across the globe.

Sincerely,

 

Dan Mills, MD
Gluteal Fat Grafting Task Force co-chair
J. Peter Rubin, MD
Gluteal Fat Grafting Task Force co-chair
Renato Saltz, MD
Gluteal Fat Grafting Task Force co-chair
Co-Chairs
Multi-Society Task Force for Safety in Gluteal Fat Grafting* The information in this Advisory Statement while setting forth the strong recommendations of the Task Force, should not be considered inclusive of all methods of properly performing buttock augmentation with fat transfer or as a statement of the standard of care or as a mandate to strictly follow the recommendations of the Task Force.This Advisory Statement is not intended to substitute for the independent professional judgment of the treating plastic surgeon nor for the individual variation among patients.The Members of the Multi-Society Task Force and the participating societies assume no responsibility or liability for injury arising out of any use of the information contained in this Advisory Statement.** The Inter-Society Gluteal Fat Grafting Task Force represents leading clinical plastic surgery societies, including the American Society of Plastic Surgeons (ASPS), the American Society for Aesthetic Plastic Surgery (ASAPS), and the International Society of Aesthetic Plastic Surgeons (ISAPS). Additionally, two scientific societies, the International Society of Plastic & Regenerative Surgeons (ISPRES) and the International Federation for Adipose Therapeutics and Science (IFATS) are represented and provide scientific support. The efforts of the Task Force build upon a foundation of important work by the Aesthetic Surgery Education and Research Foundation (ASERF), the American Society of Plastic Surgeons (ASPS) Regenerative Medicine Committee, and the International Society of Aesthetic Plastic Surgery (ISAPS) Patient Safety Committee. The Task Force is an unprecedented collaborative effort to address a major patient safety concern, investigate factors that lead to increased risk with gluteal fat grafting, perform scientific studies to improve safety, and educate plastic surgeons.

 

I have been a member of the American Society of Plastic Surgeons (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS) for many, many years and do not recall any advisory with the strong wording of this one.  I abandoned intramuscular injection a couple of years ago when the news of deaths from this procedure came trickling in.  I suspect all ASPS and ASAPS members will follow this advisory.  My concern is that many surgeons who do this procedure are not board certified plastic surgeons and therefore not eligible for ASPS and ASAPS membership.  I hope they get this message and change their techniques.  I have seen a few Instagram posts and videos of butts being pumped up to the max that make my head spin and my backside ache.  The only true way to put this dangerous procedure in the rear view mirror is for patients to stop asking for it.  There are docs (and non-docs) out there who will do just about anything if the patient is willing to take the risk.  That Kim Kardashian butt is not worth dying for!

Thanks for reading and please follow me on Instagram @sowdermd and @breastimplantsanity.  

Dr. Lisa Lynn Sowder

Body Contouring, Fat Injection, Patient Beware, Patient Safety

Spectators in the OR

June 18th, 2018 — 10:30am

Occasionally I have a request from a patient’s friend or family member to come into the OR to “watch the surgery.”  Many times they tell me that they have seen it on T.V. or on YouTube and just think it will be cool to see it in person.  The answer is always no and here is why.  In the OR, what may look like a relaxed and even fun atmosphere is actually a very carefully planned and executed choreography with several participants front stage and more in the wings.  There is me and the scrub tech at the table and sometimes one of the 6th year plastic surgery residents from the University of Washington.  Then there is the anesthesiologist keeping the patient asleep and safe and then there is the circulating nurse who helps the anesthesiologist and also opens equipment and  supplies as needed.  There really isn’t any extra room for a spectator and that spectator really isn’t going to see much because the surgical field is surrounded on all sides by anesthesia, the Mayo stand with the instruments and people on both sides of the table.  And we keep OR “traffic” to a minimum because of infectious issues.  The more people in and out of the OR the greater chance of contaminating the surgical field.  And a lay person has very little concept of the sterile field and probably has not even heard the term “sterile conscious.”  Don’t take it personally but we surgery types think lay people are just walking talking fomites.

“Jesus Christ! I think you are doing that wrong!”

And then there is “going to ground” factor.  Even the most hardened lay person or even a doctor or nurse may react very differently to the sight of blood when that blood is that of a close friend or a loved one.  If that person goes to ground, then we have another patient to take care of!

I have to tell just one little story about a would be OR spectator from my residency days.  I was rotating at Children’s Hospital in Salt Lake City and doing an infant hernia case with the Chief of Pediatric Surgery, the wonderful Dr. Dale Johnson.  One could not imagine a more competent and kind and ethical surgeon than Dr. Johnson.  He was and even after retirement is a deity in surgery circles.  We scrubbed our hands and arms and went into the OR for gowning and gloving.  He noticed an extra person in the OR with a clipboard. (Surgeon’s have a visceral distrust of people with clipboards).  Dr. Johnson politely asked this lady who she was and why was she here.  She told Dr. Johnson that she was a “patient advocate” there for the patient’s protection.  Dr. Johnson politely asked her from whom she was protecting the patient and if she was going to let him know if he was doing something wrong.  She became flustered and just left the OR and I have never seen or heard of such a “patient advocate” since then.  It was very strange and makes me think if a patient or patient’s parent think they need an advocate in the OR other than their operating surgeon, maybe they should choose another surgeon.

So go ahead and ask to be an observer but just be prepared to hear “no” in the nicest possible way.

Thank you for reading and I would be honored if you followed me on Intragram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

My Plastic Surgery Philosophy, Patient Safety, Plastic Surgery

Silicone injections are deadlier than ever.

March 13th, 2018 — 2:34pm

Silicone has quietly become beauty’s own modern-day scourge. Here’s what you need to know about the infamous injectable.

From Haper’s Bazaar, January 30, 2018 by

We often write about—and unapologetically enjoy receiving—popular cosmetic injections, like line-relaxing Botox and hyaluronic acid fillers. Thankfully for our foreheads and lips, the FDA has deemed these injectables safe and effective. And we trust our board-certified dermatologists and plastic surgeons to administer these treatments 100 percent appropriately.

Marilyn Reed is spending 8 years in prison for her buttock enhancements done with industrial grade silicone and a calking gun. Her patients didn’t get off so easily.

But a disturbing number of news reports have surfaced detailing unlicensed providers injecting all kinds of life-threatening stuff—from industrial silicone to lamb fat—with the goal of Kardashianizing women on the cheap. The FDA issued a safety alert late last year warning the public of the catastrophic risks involved with liquid silicone injections in particular.

All over the country, “people are dying from these shots,” said Beverly Hills liposuction surgeon Aaron Rollins, echoing statements in the FDA alert. Silicone, a permanent synthetic substance, is not FDA-approved for cosmetic purposes, but since it was greenlighted in the 1990s for certain uses in ophthalmology (serious stuff, like retinal detachment), injecting it into the skin to plump and fill lips, breasts, and butts is technically considered “off-label”—i.e. not illegal.

Still, the insidious goo is an infamous troublemaker. “I wouldn’t touch it with a ten-foot pole,” adds Rollins. “It may look good at first, but over time, the body forms scar tissue around it, so the injected area keeps growing and growing, as the silicone weaves its way into your tissues, becoming lumpy and hard, and nearly impossible to remove.”

Subtract an experienced injector from the equation, and silicone goes from dicey to deadly. “You hear about these so-called pumping parties at hotels, where unlicensed doctors visiting from other countries are injecting patients with massive doses of silicone,” says Dr. Clyde Ishii, president of the American Society for Aesthetic Plastic Surgery (ASAPS). “They’re literally buying it from Home Depot or Lowe’s,” he explains, “because it’s so much cheaper and easier to get than medical-grade silicone.” To lower their cost even more, some of these unlicensed doctors mix in toxic filler-type materials, like cement and motor oil, says Miami dermatologist Manjula Jegasothy. “Even in Beverly Hills,” notes Rollins, “there are people using caulk guns to inject stuff into women’s bodies, and tragic things are happening.”

It’s not uncommon for these unlicensed practitioners—inexperienced with human anatomy—to inadvertently shoot silicone into a blood vessel. And when they do, it can travel to the heart or lungs, blocking blood flow, and causing sudden heart attacks and strokes. The risk is especially high when injecting the vascular buttocks. Yet, for some, silicone’s price tag is just too good to pass up. According to Atlanta plastic surgeon Wright Jones, “Silicone butt injections may cost a tenth of the price of a legal gluteal enhancement using one’s own fat”—which is currently regarded as the most effective way to boost a backside. A Brazilian Butt Lift, using liposuction and fat transfer, can cost upwards of $10,000.

In light of the recent wave of silicone horror stories, and with butt augmentation fast becoming one of the most popular plastic surgery procedures in the U.S., not to mention a burgeoning business for untrained injectors, the Aesthetic Surgery Education and Research Foundation (a division of ASAPS) felt compelled to publish a safety protocol for gluteal fat grafting in the current issue of the Aesthetic Surgery Journal.

That’s not to say fat is the only safe solution for a shapeless bottom. Many dermatologists and surgeons do use FDA-approved cosmetic fillers “off-label” here— to either produce an immediate, yet temporary, lift from hyaluronic acid gels; or a gradual, long-term improvement from the collagen-stimulating Sculptra (which is currently only approved to soften the appearance of nasolabial folds). But such shots can be wildly expensive.
Which brings us back to silicone and its unfortunate recipients, many of whom are millennials, says Jones. At age 22, Heather*, a model in Los Angeles, visited a Koreatown medical spa for silicone butt injections. “I was booked to do a big photo shoot, and wanted my bum to look perkier,” she says.

About six months later, she noticed several golf ball-size lumps in her bottom, a common side effect of silicone. On the advice of a trusted friend, Heather says she went to see Rollins, who was able to camouflage the hills and valleys by liposuctioning fat from her arms and injecting it into her butt—an $8,000 fix.

Lips have long been another hot spot for silicone. Tired of having to draw on a juicer pout each morning, Madeline paid $50 to have her lips injected with silicone in a salon basement in Queens when she was 26 years old. Now 40, she says, “I feel like I messed up my mouth for the rest of my life.”

The size and shape of her lips change daily, often with the weather. “Usually in summer [the silicone] lays okay, but in the colder months, it moves around a lot, and concentrates in one area, bulging out.” To have her smile repaired will cost roughly $10,000, she’s been told, and surgeons can’t promise a total improvement.

Cosmetic injections should only be performed by board-certified dermatologists or plastic surgeons. If your injector is not, ask thorough questions about their training and experience. How many years have they been injecting patients? What formula are they using? If you’ve found the injector through a bargain website or coupon—the deal is likely too good to be true. The bottom line: Heed the warnings. “Don’t allow silicone into your body—ever,” says Rollins. At best, “you’ll be buying a problem for the rest of your life.”

Now a word from Dr. Sowder:  The above article is very well written and is not, I repeat, is not alarmist.  People are dying from these injections and others are being maimed for life.  I have taken care of a couple of ladies who had silicone injected into their breasts in Asia and cleaning this up is such a mess.  Whenever I hear about another silicone injection disaster, usually done by a non-physician in some hotel room, I just shake my head.  I mean, really, how dumb can you be?  I do not endorse blaming the victim but in cases like this I think the person allowing a charlatan to inject their butt or breast with silicone bears some responsibility.  Those on the other end of the calking gun need to go to jail and many in fact have.  The lesson here is that you get what you pay for.

Kudos to Ms. Edgar for a cautionary tale and to Harper’s for publishing it.  Thanks for reading and don’t let anyone get near you butt or breast with a calking gun!  Dr. Lisa Lynn Sowder

 

Body Contouring, General Health, Patient Beware, Patient Safety, Plastic Surgery, This Makes Me Cranky.

Plastic Surgery FAQ: I’m a total wreck. Where should I start?

June 14th, 2017 — 4:16pm

Seattle Plastic Surgeon answers Plastic Surgery FAQ:  I’m a total wreck.  Where should I start?

faq total wreckI often see patients who are interested in several different procedures.  They have a laundry list of things they would like to change.  A recent example was a middle aged lady who wanted hip liposuction, a face lift, a tummy tuck, a breast lift and an otoplasty to pin back her protruding ears.  Geeze, it would be unsafe and impractical to do all of those procedures in one mega 12 hour case.  It would be unsafe because that is a long, long time to be under anesthesia, multiple areas of the body would need to be exposed and that increases the risk of hypothermia, although any one operation has very little blood loss, all those procedures combined could significantly lower her blood count, and she would be sore from head to toe making her post operative recovery miserable.  It would be impractical because I really can’t stay at my best in the OR for 12 straight hours.  I just can’t.  And my nurses and techs and anesthesiologists don’t want to work a 12 hour case and we would finish the case well after dinner time.

My advice to this patient is to start with the area that bothers her the most.  In her case, it was her abdomen.  So we made the decision to do her hip liposuction and her breast lift at the same time as her abdomen.  By grouping these procedures, she saves some money and it saves her a lot of recovery time.   And – this is really important- I won’t be fatigued when I am putting in those last few stitches and the anesthesiologist will still be awake!

So if you are contemplating several procedures, try to decide which procedure you want the very most.  We can usually group procedures and still keep it safe and practical.

Oh, one more thing.  Sometimes the place to start is not the operating room.  It may be smoking cessation, getting into better shape or even a serious medical skin care program.  Sometimes surgery is the last stop on the line to improving appearance.

Thanks for reading! Dr. Lisa Lynn Sowder

If you think you are a total wreck and don’t know where to start, give my office a call to schedule a consultation, (206) 467-1101.

I would be honored if you followed me on Instagram @sowdermd and @breastimplantsantity. See you there!

Mommy Makeover, Patient Safety, Plastic Surgery, Surgical Eductaion

Seattle Plastic Surgeon Saves Resusianne (for the umpteenth time).

March 14th, 2016 — 12:16pm

Resusianne saved once again by Seattle Plastic Surgeon. 

Last Saturday I had my biyearly Advanced Cardiac Life Support review and examination.  After an excellent review of heart rhythms, various resuscitation drugs,  much studying and fretting and sweating bullets while taking the written exam, I was taken into a small room by a seasoned and tough-as-nails intensive care unit nurse.  There, on the table, lay Resusianne.  After many years of saving her life, I just call her Anne for short.  I don’t really care for her much but only because she makes me so nervous.  You see, she is always trying to die on me.

Resusianne lives yet again.

Resusianne lives yet again.

My nurse examiner starts with the scenario that I’m in Nordstrom’s and come across a woman who is laying, unmoving on the floor.  My first thought is sticker shock at the price of this bikini but I keep that to myself.  I automatically go though the drill that has been beat into me over three decades.

“Anne! Anne! Are you okay?”  Of course she’s not okay.  Resusianne is never okay but it seems polite to ask.  “I need help!  Someone call 911 and someone bring an AED.”  And then I start CPR.  Now the fun starts when the AED arrives.  I have to fumble for the on switch, rip open Anne’s shirt (fun!) and put on the paddles and then start CPR again until the AED tells me to stop.  And then it seems like an hour before the AED decides to shock Anne.  As soon as the shock is completed, I start in on CPR again until the nurse has mercy on me and tells me I can stop.  Good CPR is really, really physical, especially for a petite little gal like me.  By this time, I am a nervous wreck.  I take Anne’s problems way too personally.

Normal Sinus Rhythm is a beautiful thing.

Normal Sinus Rhythm is a beautiful thing.

Next, my examiner gives me this scenario:  I’m in the operating room with a patient and her EKG shows a heart rate that suddenly goes from 68 to 135 and her blood pressure starts to drop.  This is the arrhythmia part of the test.  You know that nice normal EKG pattern we always see with a spike between two humps? That is called normal sinus rhythm and that is what we love to see on an EKG but Anne is such a drama queen.  She’s never in that rhythm for long.  There are a dozen or so aberrant rhythms that range from kind of ugly to downright terrifying.  Her current rhythm is somewhere in the middle and responds to a nice dose of Adenosine.  She converts to normal sinus rhythm.  Woo Hoo!   But there she goes again.  Fie on her.  I give her a second and larger dose of Adenosine which really works this time.  After Anne is conscious, I tell her that I will never, ever operate on her again and that she needs to find another plastic surgeon with larger cajones than mine.

And then my examiner raises the bar.  This time Anne has just walked into my office to get her tummy tuck stitches out and she goes to ground right in the middle of my really nice waiting room!  How rude.  I go through all the steps of CPR and get EKG monitoring set up  which shows normal sinus rhythm but Anne has no, nada, zero, zilch pulse.  So now while I’m doing CPR and getting an IV started and pushing epinephrine I have to figure out why it is that Anne’s heart has electrical activity but is not pumping blood.  There are about 12 reasons this can happen and I start with the most common in this scenario which is a pulmonary embolus (a blood clot to the lung).  Now, after some IV fluid and epinephrine,  Anne has a little bit of a blood pressure and I am ready to inset a breathing tube and get her over to Swedish Hospital for a diagnostic CAT scan and treatment and I’m about to have a cardiac arrest myself with my nurse examiner tells me that my exam is over and I passed!   WOO HOO!  I’m good for two more years and now I get to go change my scrubs which are soaked with sweat.  I really, really hope I never have to use these skills.  But I’m glad to keep up to date …..just in case.  I say goodbye to the examiner but not to Anne.  I may have a different examiner in two years but I know Anne will be back.  She always is.

Thanks for reading and if you don’t know CPR, get thee to a class.  The life you save my be of someone you love!  Dr. Lisa Lynn Sowder

General Health, Patient Safety

A cancelled operation is like an empty airliner taking off.

October 14th, 2015 — 2:58pm
blog empty airline

An empty airline is almost as sad and an empty operating room.

Yesterday I had to cancel a case.  This patient was having a tummy tuck and I do not do tummy tucks on smokers.  She showed up for her surgery and confessed that she indeed had not completely quit smoking but was only smoking about 5 cigarettes a day.  Even that relatively small amount of nicotine puts her at significant risk for major healing problems and also puts her at risks for anesthesia problems because of airway irritability and increased secretions.

Soooo……………………we canceled her surgery, much to her disappointment.  This lady had arranged for time off work, child care, a caregiver for herself etc.  I don’t blame her for being disappointed and I have to say that I was a little disappointed too.  I had assembled an anesthesiologist, two registered nurses and a surgical tech not to mention my operating room.   And there we were, ready to go with no patient.  Canceling a case is sort of like flying an empty airliner around.  Lots of overhead but no paying passengers.

I am grateful that this patient was honest with us about her smoking.  I would much rather have an empty airliner on my hands than a surgical complication.  We got her rescheduled for after the first of the year and this time, I think she will take the no smoking instructions more seriously.

Thanks for reading and please don’t smoke.  Sometimes it can just ruin a good case.                                                                                                                                                                                    Dr. Lisa Lynn Sowder

Patient Safety, This Makes Me Cranky., Tummy Tuck

Do I have to cancel my surgery because of a common cold?

October 8th, 2015 — 9:14am

Fall is the time of year when we get a lot of questions about the common cold.  Murphy’s law dictates that about week before surgery, patients wake up with a sore throat and a runny nose and a sinking feeling that we will cancel their upcoming surgery.  Here are the guidelines my anesthesia and nursing staff and I use:blog common cold

A significant cough will probably require rescheduling of most surgical procedures, especially those done with a general anesthetic.  General anesthesia can irritate the airway and make a cough worse.  Also, some procedures, tummy tuck for instance, does not go well with a cough.  If the cough is minor and is likely secondary to post nasal drip, it may be okay to go ahead with surgery.  Most of the narcotic pain meds we prescribe after surgery are also powerful cough suppressants.

A mild sore throat with no other symptoms is probably not a reason to cancel surgery.  The anesthetic may make your sore throat a little worse for a day or two.   A raging sore throat with swollen, nasty tonsils is a reason to cancel surgery.

A runny nose without other symptoms is not likely to interfere with anesthesia or recovery but a nasty sinus infection, either viral or bacterial, should be resolved prior to surgery.

A fever will require rescheduling your surgery.  Fever is indicative of something bad enough to get your body fighting back.  You don’t want to pile on with surgery.

We always appreciate a “heads up” if a patient thinks there is something brewing that may affect their surgery.  Don’t hesitate to give us a call!

Thanks for reading!  Dr. Lisa Lynn Sowder

 

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Anesthesia, General Health, Patient Safety, Preoperative Care

A victory for truth-in-advertising.

September 11th, 2015 — 4:22pm

 

Appeals court affirms previous victory for Utah Society, ASPS, ABPS truth-in-advertising efforts

blog cosmetic surgeons

The 10th District U.S. Court of Appeals in Denver, Colo., on Aug. 31 upheld the September 2013 dismissal of a lawsuit filed by an ENT and oral surgeon against the Utah Plastic Surgery Society (UPSS), ASPS, the American Board of Plastic Surgery – as well as 19 individual plastic surgeons – which had contended that patient-safety education advertisements amounted to monopolistic efforts and messaging that caused direct financial damage to the non-plastic surgeons.

The appellate court decision provides another victory for patient safety and organized plastic surgery, while also serving as implicit validation of the ASPS “Do Your Homework” public-education campaign to improve patient safety.

The plaintiffs claimed in the original complaint that the Utah Society’s advertising – specifically billboards posted along one of Utah’s main interstate highways, as well as media interviews modeled after the “Do Your Homework” campaign – were in violation of the Sherman Antitrust Act and amounted to false advertising claims in violation of the Lanham Act. The plaintiffs asserted that the campaign was deceptive by indicating that cosmetic surgery is safer when performed by plastic surgeons rather than cosmetic surgeons.

The Appeals Court concluded late last month that the plaintiffs failed to show any plausible antitrust or deceptive advertising violation, and it affirmed the previous ruling in favor of UPSS, ASPS, ABPS and the individual plastic surgeons named in the lawsuit.

“This decision further confirms the value and importance of our efforts to instill public awareness on the distinctions between ABPS-certified plastic surgeons and lesser-trained physicians who present themselves as similarly skilled,” says UPSS President Brian Brzowski, MD. “We were helped tremendously by ASPS through its early financial and material support and its guidance in crafting the overall ‘Do Your Homework’ effort.”

“Despite the hurdles we have had to cross in dealing with the lawsuit, I was always supremely confident that we would prevail in promoting safe plastic surgery in Utah and beyond,” adds UPSS immediate-past President Trenton Jones, MD. “This public-safety education campaign was modeled largely after the ASPS campaign, so it’s a victory for organized plastic surgery and a huge win for the Utah Society.”

“We’re pleased that the legitimacy of the public-education efforts of UPSS and ASPS have been recognized yet again by the federal court,” says ASPS President Scot Glasberg, MD. “We applaud the Utah Society for taking a stand for patient safety and our specialty – and we welcome any local, state or regional society to confer with the leaders of the ASPS Public Education Campaign to raise awareness and promote patient safety in their states and localities.”

ASPS acknowledges Dr. Brzowski, Dr. Jones and the Utah Plastic Surgery Society for their efforts to both bring the ASPS “Do Your Homework” campaign to their state, and for defending patient-education efforts.

Thanks for reading!  Dr. Lisa Lynn Sowder

Patient Beware, Patient Safety, Plastic Surgery

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