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

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A must read article about COVID-19

March 19th, 2020 — 1:52pm

Please read this article for some excellent information of COVID-19.  

My office and ambulatory surgery center is shutting down for at least a month.  We will have a skeleton staff answering the phone and I will be available in person for only those who really need a face to face with me.  I am 63 and thus at high risk despite enjoying excellent health and feeling and sometimes acting like I’m 14.  I thank all my patients who have had to reschedule their surgery and I thank everyone who takes this seriously.  And for those who don’t, get a clue already.

Stay safe, stay strong, stay sane, and stay in touch.

Dr. Lisa Lynn Sowder.   Follow me on Instagram @sowdermd and @breastimplantsanity.

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Can Surgery Be A Placebo?????

February 21st, 2020 — 11:45am

A few weeks ago I listened to an excellent Hidden Brain Podcast about placebos and not just the sugar pill kind of placebo.  This podcast recounted an amazing clinical trial done way back in 2002 which put the very common procedure of arthroscopic knee surgery for osteoarthritis to the test.  I will summarize that study here but I really encourage everyone to listen to the podcast.  There are also some links to the original paper published in the New England Journal of Medicine.

In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.

So here we go with my summary:  180 patients with osteoarthritis of the knee were randomly assigned to one of three groups.  The assignments were controlled for severity of disease.

Group 1 : Routine arthroscopic surgery to wash out and clean up any irregularities in the knee joints

Group 2:  The incision was made, the arthroscope was inserted and the knee joint washed out (lavaged) but nothing else was done.

Group 3:  An incision was made but the arthroscope was never inserted.

The patients did not know which group they were in nor did their families or the nurses who cared for them after surgery.   The surgeon and the operating team did not know which procedure the patient would have until the patient was on the OR table and anesthetized and the randomization envelope was opened.  For groups 2 and 3, a video of standard knee surgery was played and the OR team sort of faked the movements of the surgery and the time in the OR was the same for all groups.  One surgeon did all of the cases.  Group 1 is the real operation, Group 2 is the lavage group and Group 3 is the sham procedure.     Now some commentary on this study.  These patients had honest to goodness osteoarthritis of the knee confirmed by history, exam and X-Rays.  This was not a group of patients with ill defined and subjective complaints.  These were patients with objective disease. .

Follow up at two years showed no statistically significant difference in relief of symptoms as reported by the patients or function as measured by walking and climbing stairs between Group 1 (real surgery), Group 2 (lavage only) and Group 3 (sham surgery).   Think about this for a moment……….An arthroscopic clean out of the knee joint had no more effect than a superficial skin incision.  

I remember the reaction to this study when it was published.  At that time I did a lot of my surgery at Seattle Surgery Center and I had the opportunity to hob nob with a lot of orthopedic surgeons.  The ortho bros often teased me for all the unnecessary surgery I do.  Yeah, it’s true.  The vast majority of cases I do are unnecessary.  This study allowed me to tease them about their “scoping for dollars” practices.  I think a lot of scoping for dollars still goes on (mostly because patients request it) but maybe a little less since this paper smacked everyone upside the head.

Isn’t it just amazing what the human mind can do?  It can convince the body that the sugar pill was the real thing or even that the sham surgery was the real thing!

Thanks for reading and really you should listen to this podcast!   And as usual, I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

 

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Some suggestions for New Year’s Resolutions

December 31st, 2019 — 12:30pm

 

I cannot improve on this list of Woody Guthrie’s.

blog new yearsThanks for reading and Happy New Year!

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

Dr. Lisa Lynn Sowder

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Opioid Free Surgery

May 20th, 2019 — 9:08am

I am very pleased to introduce our new opioid free surgery protocol.  This has been in the works for several months and we launched it 3 weeks ago with very good feedback from our patients.  Here’s just about everything you need to know.

Why?    The use and abuse of opioids cause a lot of problems not just for patient but society at large.  On the patient level, opioids often cause side effects such as itching, nausea, constipation, fuzzy head, bad dreams and the list goes on.  Having been on opioids myself for various surgical procedures, I personally think they don’t do a very good job at controlling pain but just get you so fuzzy in the head that you just don’t care.   On a societal level, have you heard of the opioid crisis?  The fewer pills out there in people’s medicine cabinet will mean less abuse.

How?   By approaching anesthesia and post operative pain in a different way, pain control can actually be better than what we have achieved in the past with opioids.  The non-opioid medications are started pre-operatively to provide a preemptive strike against the pain cycle.

What?  Here are the medications we use.  Acetaminophen a.k.a. Tylenol:  It’s good for head aches and post op pain.  Celecoxib a.k.a. Celebrex:  this is a non-steroid anti-inflammatory but does not have the blood thinning effects of other NSAIDs such as ibuprofen.  Inflammation is a major factor in pain.  Gabapentin a.k.a. Neurotin:  This is a medication used commonly for nerve pain.  It has a mild sedating effect in some individuals but does not fuzz your head nearly as much as an opioid.  Marcaine and/or Exparel:  These are long acting local anesthetics that are injected into the operative sites that can render the injected area numb for hours or days.  Ice: Oh, yeah, ice packs can help a lot.  My husband got through a gnarly knee operation with virtually nothing more than Tylenol and a gizmo that surrounded his knee with ice slush, provided by his awesome caregiver (that would be me).

When?  We have out patients take a dose of Tylenol, Celebrex and Gabapentin a couple of hours before surgery with a sip of water.  During surgery, the surgeon injects the operative area with local anesthetic.  After surgery, the patient continues with the medication combination.  Ice packs can be added for most types of surgery but check with us first.

Who?  All of us – surgeons, anesthesiologist, nurses, patients and their caregivers.  This protocol requires that we all work together.  The patients must make sure to take their medication before surgery, anesthesia must minimize or eliminate the use of opioids during surgery, the surgeon must be thorough with injection of the local anesthetics, the nurses must be sure the patients and their caregivers understand the pre and post-operative instructions.

So, how’s it working?  So far I have had a dozen patients on this protocol including a tummy tuck patient with very, very favorable results. I am very excited about this plan.  I’m sure we will tweak it here and there a bit but thus far I’m a total fan.

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

Dr. Lisa Lynn Sowder

 

 

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Capsular Contracture 102: Treatment

April 19th, 2018 — 3:59pm

My last blog discussed the difficult and frustrating problem of capsular contracture of breast implants.  As with just about every problem known to mankind, prevention is the best approach. But despite doing everything correctly pre-operatively, intra-operatively and post-operatively, a small number of patients will experience capsular contracture.

First a little history:  Way back when the Earth was cooling and breast implants were the newest and coolest thing, surgeons would treat capsular contracture by “popping” the breast, the so-called manual or closed capsulotomy.  Here is how it worked.  The surgeon would take his great big strong paws and basically mash the poor breast until there was a pop and the breast went soft as the scar capsule ruptured and released its pressure on the implant.   As you can imagine, there was a lot of moaning and screaming in the exam room during this process.  It wasn’t long before surgeons realized that: 1. the capsular contracture always came back, 2. this can rupture a breast implant, 3. this can cause acute bleeding and 4. women don’t like being manhandled this way.  I was just starting my training in plastic surgery just as manual capsulotomy was falling out of favor.  I’m happy to say that I have never done this crude procedure and it is likely that I would not have succeeded had I tried.  I have teeny tiny and not-so-strong hands.  I would have likely ruptured one of my tendons before rupturing a capsule or implant.

Okay, that was then and this is now.  For early capsular contracture, it’s worth trying medication.  A dozen or so years ago it was observed that implant patients on a certain kind of asthma medication has a very low rate of capsular contracture.  These medications are leukotriene receptor antagonists and they work for asthma by reducing inflammation.  And inflammation is thought to be the final common pathway to capsular contracture.  The two medications used are zafirlukast and mohnelukast.   Accolate and Singular are the brand names respectively.  I have had several patients resolve an early capsular contracture with these medications. I have also had a few patients who did not respond to these medications

These implants were 41 years old and had a grade 4 capsular contracture. I removed them and the capsule and inserted new implants. She is shown 18 months after surgery.

Once a capsule is well established, surgical intervention is the only way to resolve it.  Complete capsulectomy removes the scar tissue and then the question  is how to prevent a recurrent capsule.  And does it make sense to just pop in another implant right away?  This is just such a difficult question because none of us has a crystal ball to tell the future.  Sometimes capsulectomy and a new implant works great but sometimes another capsular contracture starts forming despite doing everything right.  Sometimes we create a new pocket and make a pocket under the muscle if the over the muscle implant had a capsular contracture and vice versa.  Adding Accolate or Singular makes some sense.  Sometimes adding a piece of acellular dermal matrix like Strattice (which should be spelled  $$$$trattice) will decrease the chance of another capsule.  And whenever there are several different approaches to a difficult problem, you can be sure that none of them works every time.

The only surgery I know of that will for sure prevent another capsular contracture is implant removal and total capsulectomy without implant replacement.  This definitive treatment is readily accepted by many of my older patients who are sick and tired of their nasty, rock hard and uncomfortable implants.  They look forward to being implant free.  For younger patients, however, this can be a very, very difficult thing to accept, especially if they were really, really flat to begin with.  I have at least one patient that comes to mind who had several capsular contracture related surgeries by me and finally we just threw in the towel and removed her implants along with her capsules.  Her breasts returned pretty much to their preoperative size and shape but let me tell you, her wallet was never the same.  A problem with capsular contracture can be very, very expensive and result in a lot of down time – off work, off exercise, off fun.  This particular patient went on to have some fat transfer several years later and did well.  She and I are both glad to have her implant saga behind us.

Just writing this post makes me feel like I never want to do another breast augmentation!  And then I think of the patient I saw in clinic this morning.  She was very, very flat chested and was too lean to consider fat transfer.  I inserted 250 cc low profile cohesive gel implants last week and this morning I could not wipe the smile off her face.  I think as long as there is Victoria’s Secret, there will be a demand for breast augmentation.  I am just grateful that implant technology keeps improving as does our surgical technique.  Hopefully sometime in the near future capsular contracture will be of historical interest only.

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

Breast Contouring, Breast Implant Removal, Breast Implants, Plastic Surgery, Uncategorized

How to lose weight in 4 easy steps by

February 14th, 2018 — 7:39am

I thought I would post this essay for Valentine’s Day.  It’s really not about losing weight.

This is cut and pasted from http://aaronbleyaert.tumblr.com/post/109959086957.  All I added was the cartoon.

HOW TO LOSE WEIGHT IN 4 EASY STEPS

I’ve spent the past year losing 80 lbs and getting in shape. A lot of people have been asking me how I did it; specifics like what diet I was on, how many times a week I worked out, etc etc. So I thought I’d just answer everyone’s questions by giving you guys step by step instructions on how you can achieve everything I have… IN JUST 4 EASY STEPS! Ready? Here we go!!!

1.) NO BEER
This is a big one, and one that you’ve probably heard before. Every time you drink a beer, it’s like eating seven slices of bread. That’s a lot of bread!

2.) PORTION CONTROL

Portion control according to B. Kliban

Portion control according to B. Kliban

This is especially true when you go out to eat at restaurants. A good trick to do is when your meal comes, cut it in half and right away ask for a takeout container, so that you can save the rest for later – and even better, if you start your meal out right by ordering lean meats and veggies, you’ll slim down in no time!

3.) HAVE YOUR HEART BROKEN
And not just broken; shattered. Into itsy bitsy tiny little pieces, by a girl who never loved you and never will. Join the gym at your work. Start going to the gym regularly, and even though you don’t know that much about exercise and you’re way too weak to do pretty much anything but lift 5 lb weights and use the elliptical machines with the old people, do it until your sweat makes a puddle on the floor. Then go home and go to bed early and the next day do it again. And then again. And then again.

Listen to stories of your ex-girlfriend fucking around with gross and terrible people, stories from your friends who think they are doing you a favor. Go to the gym and make more puddles of sweat. Buy books. Learn about different muscle groups and how they work together. Start eating healthy. Learn about nutrition. Plan out your week of meals. Try to forget her.

After work one night, go up up up all the way to the top floor of the parking garage and walk all the way to the back. Look out at the twinkling lights of the skyscrapers of downtown Los Angeles and think about how every single one of those office lights represents a person. Try to imagine how they feel. What they’re doing right then; if they miss someone special, if they wonder if someone special misses them. Then realize that most of those lights are probably shining into offices with no one in them except for a custodian or two. Realize you are alone, that you are staring at no one. Turn your collar up against the cold and drive home to a meal of a single chicken breast and steamed vegetables. Go to sleep. Go back to work. Go to the gym. Sweat.

Buy a scale. Pick a goal weight. Imagine the goal weight as a shining beacon on a hill. You are at the bottom, in the dark. Talk to her at work. Notice the awkward way she walks in high heels and her goofy smile when she looks over at you. Feel something clench inside your chest. Think about the gym and what muscle groups you are going to work that night.

Get on the treadmill. Push yourself to level 3, then level 4. Then 6. Run so fast you feel like you are going to die. Hit level 10. Pray for death. Think of how bad she makes you feel. Find the strength to keep going.

Late one night, make the mistake of looking at her Facebook and Instagram posts. Feel lower than you ever thought possible. Unfriend her and try to forget what you’ve seen. She is doing things with other people that you asked her to do with you. She is having a great time without you, and you are wasting your life listening to Taylor Swift on repeat and making sweat puddles on a gym floor.

Watch as your life shrinks down to four things: 1.) work, 2.) the gym, 3.) the food you eat, 4.) sleep. She wears the necklace you bought her and tells you that she got it “from someone who’s really special”. That night you discover that Slayer’s “Angel of Death” might be the perfect song to do squats to.

Start to make friends at the gym. Vince and you spot each other on Wednesdays; Chase and you spot each other on Fridays. You used to look down on bro nods and fist bumps – but since that’s how gym rats communicate, that’s become the language you speak most often. Work, Gym, Food, Sleep. Over and over. More sweat puddles. More fist bumps. You run hundreds of miles and lift thousands of pounds.

You start to see new people working out here and there and you realize you have done something you once thought impossible: You have become one of the regulars. Once in a while, you are the last one leaving the gym. You make a point to get to the gym earlier, but your workouts start to stretch from one hour to ninety minutes to two hours. You are now routinely the last person at the gym. You run. You lift. You make more puddles.

Your body changes slowly, then all at once – you are suddenly thin and muscular. You hit your goal weight, pick a new one, then hit it again. You go out and buy new clothes. You receive wave after wave of compliments. Your ex tells you that she’s seeing someone else. Your chest clenches. You feel exhausted.

That night you go to the gym. You listen to all her favorite songs. You run farther and lift more than you thought your body was capable of. It is a good workout. It leaves you numb. You go home and eat a single chicken breast and steamed vegetables. You go to sleep. You dream of a bottomless black puddle.

You’ve stopped drinking alcohol months ago, so now when you hang out at bars or parties you don’t talk to anyone new. But with your new body and new clothes, gorgeous women hit on you constantly. One time, a woman literally comes up to you and says she thinks you’d be good in bed and hands you a napkin with her number on it. As she is talking to you, her hand resting on your chest inside your shirt, all you can think of is how badly you need to beat your best time sprinting across the park across from your house the next day. That night when you get home you research the best shoes for trail running and click “buy”. The shoes are a hundred dollars. The phone number goes in the trash.

There is a girl you see a lot at the gym, who always does these weird leg exercises you’ve never seen before. She’s beautiful. You make it a point to not look at her – because you are overly worried about looking creepy like that guy in the blue shirt who never wears underwear and always hangs around the lat pulldown machine – but you notice this girl is always at the gym when you are, and seems to always choose the bench next to you. You turn up the Slayer and concentrate on making your puddles bigger.

Your ex parades her new boyfriend around, flatly ignoring you the entire time. He is taller than you, more ripped than you, better looking than you, and – according to the Greek chorus of your mutual friends – he comes from money. As you watch her introduce him to everyone but you, you remember how her blue eyes lit up underneath the ferris wheel on her birthday when you gave her those bracelets she’s wearing. In your pocket, your hand makes itself into a fist.

That night, you deadlift your body weight. You sneak a photo of yourself in the mirror and email it to yourself with the subject heading “You Are A Warrior”. The next day you are disgusted with yourself and delete it.

You make puddle after puddle after puddle and eat single chicken breasts and work and sleep and the weather gets warm and then gets cold and you know all of Taylor Swift’s songs by heart and the only things that exist in the entire universe are you and The Gym and then something different happens: a night comes where you are not the last person in the gym.

It is you and the girl who does the weird leg exercises. You end up walking out at the same time.

Her name is Melissa and she works in the building next to you. She’s worked there for two years. She asks you out to dinner on Friday, promising it’ll be healthy. The leg exercises are Pivoting Curtsy Lunges.

You start seeing Melissa a lot, both inside the gym and out. You tell no one. You add a couple cheat days to your week – for when you two get dinner and share dessert – and you start getting a lot less sleep. You phase out Slayer in favor of Springsteen. Vince and Chase note that you’ve stopped looking like you’re praying for death when you run. Your ex texts you late at night to ask you out to coffee, but you don’t write her back. You can’t remember the last time you fantasized about puddles.

One night you’re walking Melissa to her car in the parking garage and she is parked up up up all the way on the top floor. She says she wants to show you something and she takes your hand and leads you all the way to the back. You both stand there in the dark looking out over the twinkling lights of the skyscrapers of downtown Los Angeles.

“Isn’t it beautiful?” She says. “All those lights.”

You tell her that yes, it’s beautiful, but it makes you sad. All those pretty lights mean nothing; they’re just shining into cold lonely offices with nobody in them. Melissa squeezes your hand and says yes, each light is an empty office – but they’re only empty because the people have all gone home for the day. All those twinkling lights aren’t sad; each one is a person who’s at home, happy with the one they love. And how romantic is that?

You look at her in the lights and she smiles. Something in your chest expands.

Late one Sunday afternoon you are writing out your rent check and realize it’s been exactly a year since you started working out. You think of all those miles you’ve run and those pounds you’ve lifted and chicken you’ve eaten and puddles you’ve made. It doesn’t seem that bad. You realize that it’s not about hitting a goal weight, or lifting a weight. It’s about being able to wait. Waiting, being patient, and trusting that life will slowly inch along and things will eventually get better. After all, change takes time.

But time is all it takes.

4.) NO FRUIT JUICE
Too much sugar!!!

 

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Let’s be friends, eh?

IT WAS ALL A DREAM 

Thanks for reading and I bet Aaron thanks you too.  I’d be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

 

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What might the Cuban Sonic Attacks have in common with Breast Implant Illness?

February 1st, 2018 — 8:49am

You gotta read this from today’s Slate.com.  This will involve some heavy mental lifting so put on your thinking cap and take the time to read the entire article.

MEDICAL EXAMINER
Cuba’s Sonic Attacks Show Us Just How Susceptible Our Brains Are to Mass Hysteria
The symptoms so many Americans experienced were probably not caused by a secret weapon. That doesn’t mean they’re not real.

By FRANK BURES
FEB 01, 20185:43 AM

A few weeks after the 2016 presidential election of Donald Trump, several people working for the U.S. Embassy in Cuba fell mysteriously ill. Some lost their hearing. Some had headaches and a pain in one ear. Others reported feeling dizzy or nauseous, having trouble focusing, or feeling fatigued. Later, some would have a hard time concentrating, remembering things, sleeping, and even walking.

These symptoms were “medically confirmed,” as the State Department’s medical director Charles Rosenfarb put it, and brain scans were said to show abnormalities in the victims’ white matter, which transfers information between brain regions. The illnesses were believed by the government to be “health attacks,” carried out by a foreign power, though as Todd Brown, assistant director at the Bureau of Diplomatic Security, told the Senate Foreign Relations Committee, “investigative attempts and expert analysis failed to identify the cause or perpetrator.”

Nonetheless, investigators concluded the illnesses, which ultimately affected 24 people, were likely the result of a “sonic device.” This conclusion seems to be primarily due to the fact that some diplomats reported hearing a high-pitched noise in their homes and hotel rooms.

Despite a lack evidence for such a weapon, or any known way it could affect white matter, the sonic weapon theory proved irresistible for both media outlets and for Cuba hawks like Sens. Marco Rubio and Bob Menendez, both of whom immediately transformed the sonic weapon into a handy political weapon.

In the months following the “attacks,” new diplomats arriving in the country were warned of this sonic danger. Embassy employees were played a recording of what was thought to be the sound so they knew what to listen for. Soon, people at the Canadian Embassy in Cuba began reporting symptoms similar to what the Americans had experienced, as did a few tourists there. A husband and wife at the U.S. Embassy in Uzbekistan became ill as well. Whatever it was, it seemed to be spreading.

There is increasing recognition that these epidemics of hysteria, which usually mirror prominent social concerns, present real individual and public health problems.
With no details, no motive, and no plausible explanation for what kind of weapon this might be, doubts began to surface. The FBI investigated and reportedly found there had been no such attack (though it suggested maybe it was a “viral” weapon). Sen. Jeff Flake also cast doubts on the sonic version of events. A handful of skeptical stories began to appear amid the more alarming ones, suggesting this might be what in the past was known as, “mass hysteria,” but which is now referred to as “mass psychogenic illness,” or a “collective stress response.” (These include things like the twitching girls in Le Roy, New York, in 2011; the 600 paralyzed girls in Mexico in 2007; and the Belgian Coca-Cola scare of 1999, which affected 100 students with more than 900 others reporting a related symptom, and costing the company somewhere between $103 million and $250 million.)

Epidemics of this sort are well-known in the scientific literature. Robert Bartholomew, a New Zealand–based medical sociologist and the co-author of Outbreak! The Encyclopedia of Extraordinary Social Behavior, Mass Hysteria in Schools: A Worldwide History Since 1566, and other books on the subject, has collected a database of some 3,500 cases. While the precise mechanisms are difficult to pinpoint, and the diagnosis is always controversial, there is increasing recognition that these epidemics of hysteria, which usually mirror prominent social concerns, present real individual and public health problems.

Yet many people still assume victims of such phenomena are simply faking or imagining their symptoms. In the Senate hearings on the attacks, Sen. Rubio asked Rosenfarb whether he thought this was, “a case of mass hysteria, that a bunch of people are just being hypochondriacs and making it up?”

This was a loaded question, with Rubio deploying the term mass hysteria as a means of dismissing this possibility altogether. But Rubio’s assumption—that a mass psychogenic illness is the same as faking or hypochondria—is wrong, as was his dismissal of the idea that this might explain the illnesses in Cuba. Indeed, mass psychogenic illness is likely the best explanation for these illnesses. According to Bartholomew, if you removed the word concussion from discussion of what happened there (but left the “white matter tract” changes in its place), you’d have a “textbook case” of mass psychogenic illness, in everything from its symptoms to its spread.

“There’s no evidence whatsoever that this was caused by a sonic device,” Bartholomew says. “It is physically impossible to have brain damage caused by an acoustical device. And most of those symptoms are not symptoms of sonic weaponry.” Anxiety and nausea, he notes, can be caused by both mass psychogenic illness and acoustic weapons, but the noise would have to be incapacitating and high volume. None of the other symptoms reported in Cuba are associated with an acoustic assault.

And what’s more: “This is a small, close-knit community in a foreign country that has a history of being hostile to the United States,” he says. “That is a classic setup for an outbreak of mass psychogenic illness.”

History is filled with cases of “sounds” making people ill. In Kokomo, Indiana, locals have been plagued since 1999 by a low frequency hum, which one resident said caused, “short-term memory loss, nausea, and hand tremors.” In Taos, New Mexico, a similar sound causes resident “sleep problems, earaches, irritability, and general discomfort,” by one account. Similar hums are reported in Bristol, England, and Windsor, Ontario. In 1989, a “Low Frequency Noise Sufferers Association” was formed in London. The people reporting illness from the noise produced by wind turbines have given the phenomenon its own name: wind turbine syndrome.

Unfortunately, it is also possible to lose your hearing without being attacked by a secret weapon. The Handbook of Clinical Neurology volume on Functional Neurological Disorders lists “nonorganic hearing loss” in its chapter on “Functional Auditory Disorders,” alongside conditions like musical hallucinations, misophonia (“hatred of sound”), “acoustic shock” from a sudden noise (symptoms include “pain in or close to the ear,” tinnitus, balance problems, hypervigilance, and sleep disturbance), and others. In Germany, there is a common condition called Hörsturz, which is a sudden loss of hearing related to stress. In 1973, at a nursing school in Papua New Guinea, there was an epidemic in which students were struck deaf, among other symptoms, with no apparent external cause.

“It’s very easy to manipulate people’s physical well-being through giving them expectations about sound,” says Keith Petrie, who researched the power of the mind in relation to wind turbine syndrome. When Petrie and colleagues exposed people to both infrasound and sham infrasound (silence), they found it wasn’t the sound itself, but their expectations—or what’s known as the nocebo effect—that produced adverse physiological reactions. Witnessing another person with symptoms can create an even stronger response, as can the perceived cause.

“When we gave them a plausible, biological explanation,” says Petrie, “it increased their symptoms the next time they were exposed to sound. When we gave them a nocebo explanation—and both explanations were equally credible—their symptoms decreased.”

On the surface, studies like this make it easy to agree with the Marco Rubio line of thinking that sufferers are just faking it. But the people who were told there was a medical reason for the hearing loss are not just imagining the resulting symptoms—they are physiologically real, “medically verifiable,” and cause deep distress, even if they resolve quickly, as most do.
“People suffering from mass psychogenic illness are not hypochondriacs and they’re not all making it up,” says Bartholomew. “It is a real condition with real symptoms. It could happen to anybody.”

There is real crossover between the condition’s mental origin and physical manifestation.
Research into the nocebo effect has been hampered by the ethics of subjecting people to it, but a picture of the mechanisms is emerging. And one important factor is “abnormally focused attention,” as neurologist Jon Stone puts it.

“As human beings, we’re more prone to these phenomena than we like to think,” says Stone, co-editor of Functional Neurological Disorders. “The rate of functional symptom experiences in the general population is very high. People have these symptoms a lot and just normalize them. We’re never very far from a functional disorder.”

What were once known as conversion disorders (meaning the conversion of a mental problem into a physical one) are now referred to as functional disorders. The old terms like psychosomatic or even psychogenic imply a purely mental origin, but the current parlance reflects the more complicated picture, that there is real crossover between the condition’s mental roots and physical manifestation. A “functional disorder means something has gone wrong with the network, the connections, the pathways, as opposed to the physical structure of the brain. And when these functions go wrong, normal sensations like tiredness, dizziness, or pain can grow much worse and become persistent.

One of the findings in Cuba that reporters seized on was the assertion that victims had suffered some kind of head trauma. As Rosenfarb put it, there were “clinical findings of some combination similar to what might be seen in patients following mild traumatic brain injury or concussion.” Here, he appears to be talking about abnormalities in the patients’ white matter, but a concussion isn’t the only thing that can have that effect. White matter changes with experience and learning, and becomes more robust in response to using a given pathway repeatedly. If those pathways are related to a disorder, it may appear in “diffusion tensor imaging” scans as anomalies.

“Diffusion tensor imaging,” says Stone, “is a technique that shows abnormalities in patients not only with minor brain injuries, but also with chronic pain, anxiety, depression, you name it. This is not a mark of brain injury. It’s a mark of brain dysfunction. It’s evidence that they’re ill.”

One problem in understanding the reality of a functional disorder is that most of us, when we are ill, look for a single cause, a simple chain of events that starts with an event, or a germ, and ends with our own misery. But functional disorders don’t work in this linear fashion. They are recursive and multifactorial, a feedback loop between our expectations, emotions, and physiology. According to Mark Hallett, a senior investigator at the National Institute of Neurological Disorders and Stroke, a picture of how they work is beginning to emerge, in a sense that, “when the so-called limbic system of the brain [the part of the brain that drives instinct, mood, and emotion] is overactive, it might induce the different symptoms that arise.”

Which is to say that if we fixate on our naturally occurring experiences and feelings, they can become amplified, particularly if the limbic system is overactivated by fear and anxiety. This creates a kind of loop between mind and body that it can be difficult to get out of, and which can make these conditions difficult to treat.

“It’s very powerful,” says Petrie. And often underestimated. “From the comments I read by the physician associated with the [embassy attacks], it was interesting how he dismissed this explanation” Petrie says. “He didn’t seem to understand how easily this can happen.”

Most people don’t. That includes just about everyone involved in the Cuban attacks. Mass psychogenic illnesses are not as intuitive to grasp as cold or a flu, but they are just as serious, and should be treated as such. In Cuba, they have not been. Instead, a fixation on secret weapons has obscured a real illness with real consequences, one which can not only be “medically verified,” but which regularly afflicts people across the world, and to which anyone with a functioning brain is vulnerable.

Thank you for reading!  Dr. Lisa Lynn Sowder

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

Breast Implant Illness, General Health, Uncategorized

Brazilian Butt Lift a.k.a. Fat Grafting to the Buttocks: Let’s make this safer.

January 31st, 2018 — 12:18pm

Brazilian Butt Lift a.k.a. fat grafting to the buttocks is getting a lot of needed attention considering the comparatively high mortality rate of this procedure.   Several surgical societies have come together to study these deaths and have come up with these following guidelines.  Hopefully this procedure will become safer.  I applaud those who did the heavy lifting and came up with these recommendations.  If you or someone you love (or even don’t love) is thinking about this procedure, make sure their surgeon is aware of and compliant with these guidelines.  A big booty isn’t worth dying for.

Multi-Society Gluteal Fat Grafting Task Force issues safety advisory urging practitioners to reevaluate technique

Dear Colleagues,

An Inter-Society Gluteal Fat Grafting Task Force** has analyzed deaths from gluteal fat injection (“Brazilian Butt Lift” or “BBL”) and offers the following advisory statement:

Not worth dying for.

The death rate of approximately 1/3000 is the highest for any aesthetic procedure. In 2017, there were three deaths in the state of Florida alone. Every surgeon performing BBLs should immediately reevaluate his or her technique.

Some patients have died when their surgeon said they had injected into the subcutaneous fat layer, but all autopsies of deceased BBL patients have had these findings in common: 1) fat in the gluteal muscles; 2) fat beneath the muscles; 3) damage to the superior or inferior gluteal vein; 4) massive fat emboli in the heart and/or lungs. No post mortem has yet shown a case of death with fat only in the subcutaneous space; this means that surgeons have injected more deeply than they had intended. The mechanism of death is presumed to be high pressure extravascular grafted fat entering the circulation via tears in the large gluteal veins with subsequent embolization to the heart and lungs.

The task force, therefore, offers these suggestions*:

1.Stay as far away from the gluteal veins and sciatic nerve as possible. Fat should only be grafted into the superficial planes, with the subcutaneous space considered safest. If the aesthetic goal requires more fat than can be placed in the subcutaneous layer the surgeon should consider staging the procedure rather than injecting deep.
2.Concentrate on the position of the cannula tip throughout every stroke to assure there is no unintended deeper pass, particularly in the medial half of the buttock overlying the critical structures.
3.Use access incisions that best allow a superficial trajectory for each part of the buttock; avoid deep angulation of the cannula; and palpate externally with the non-dominant hand to assure the cannula tip remains superficial.
4.Use instrumentation that offers control of the cannula; avoid bendable cannulas and mobile luer connections. Vibrating injection cannulas may provide additional tactile feedback.
5.Injection should only be done while the cannula is in motion in order to avoid high pressure bolus injections.
6.The risk of death should be discussed with every prospective BBL patient.
These are links to three helpful articles:

Research projects overseen by the task force and funded by The Plastic Surgery Foundation (PSF), Aesthetic Surgery Education and Research Foundation (ASERF) and International Society of Aesthetic Plastic Surgery (ISAPS) are underway. They will correlate deep and topographical anatomy, define danger zones, and try to understand the mechanism of embolization. The ability to safely perform this procedure in the future is dependent upon this research.

Members of the task force have also assisted coroners during autopsies, and this has provided invaluable safety information. If you become aware of a fatality, immediately contact the task force co-chairs care of Keith Hume, executive director of The PSF, at khume@plasticsurgery.org.

Your societies will keep you updated with all developments.

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

Thanks for reading and did you know that skating (roller, ice or skis) can really build up your gluteal muscles?  Just check out the Olympic skaters and skier this winter!  Dr. Lisa Lynn Sowder

 

Uncategorized

BIA-ALCL: What we know so far.

January 8th, 2018 — 3:13pm

I recently took an excellent online tutorial on Breast Implant Associated Anaplastic Large Cell Lymphoma presented by Dr. Mark Clemens of M.D. Anderson Cancer Center.  Here is some information from that tutorial as well as information from the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery.   I have also included information from an article in JAMA (Journal of the American Medical Association) Oncology published last week and some of my own take on this really weird disease.  Warning: this is a long one.

This is a schematic of BIA-ALCL. It is not breast cancer. It is cancer of the breast implant capsule.

Q: What is BIA-ALCL?

A: BIA-ALCL is a rare type of lymphoma that has been found in proximity to breast implants. BIA-ALCL is not a cancer of the breast tissue itself.  It is cancer of the breast implant capsule.  How weird is that???

Q: What are the symptoms of BIA-ALCL?

A: BIA-ALCL usually develops as a swelling of the breast 2 to 28 years after the insertion of breast implants, which may present as fluid collecting around the implant. It can also present as a lump in the breast or armpit.

Q: What is the risk of developing BIA-ALCL?

A: Early in 2016 the FDA issued a report that it had received 258 adverse event reports of breast implants and ALCL. For a frame of reference, both ASPS and ASAPS data report that approximately 300,000 breast augmentations are performed annually.

A: The lifetime risk for BIA-ALCL in previous epidemiological studies ranges from 1:30,000 to 1:50,000.

A: The figure derived and issued by the Australian government was in the range of 1:1,000 to 1:10,000 for Australian/New Zealand patients with textured/polyurethane implants. Polyurethane implants are not available in the United States.

A.  An article published last week (Jan. 4, 2018) in JAMA Oncology and picked up by Newsweek looked at the a large number of women with breast implants in the Netherlands.  Almost one half of the implants used in the Netherlands are textured.  This is in contrast to the implants used in the United States which are mostly smooth.  This study confirmed that this disease occurs with textured breast implant, particularly implants with macrotexturing.  The implant specific risk in macrotextured implants like those made by Allergan and Biocell was 1:3817.  The risk in microtextured implants like those made Silimed was 1:7788 and by Mentor was 1:60,631.  The reasons for that difference is not yet clear but may be related to the increased surface area of the macrotextured implants which could allow for greater bacterial contamination.

A.  Risk may also be somewhat influenced by geography (where you live) and genetics (who your parents are).  There is increasing evidence that certain bacteria and bacterial biofilm may be causative.  Infectious agents are a cause in several other types of tumors such as liver cancer (hepatitis virus) and Burkitt’s Lymphoma (malaria and Epstein Barr Virus).  There are also many cancers that tend to run in families such as breast and ovarian cancer, some colon cancers, leukemia, malignant eye tumors to name a few.  There may be a genetic susceptibility to BIA-ALCL.

Q:  Is there such a thing as ALCL in breasts without implants.

A:  Yes but it is very rare.  According to the recent JAMA report out of the Netherlands, the risk of ALCL in the absence of implants is 1 in 35,000 at 50 years of age and 1 in 7000 at 70 years of age.  The risk in women with implants (all types) is 1 in 7000 at 75 years of age.  By contrast, the lifetime risk of breast cancer for women according to the National Cancer Institue is about 1 in 8.

Q: How is BIA-ALCL treated and what is the prognosis?

A: Current recommendations for the treatment of BIA-ALCL call for bilateral capsulectomy and removal of the breast implants. In all but a few cases, the disease has been fully resolved by this surgery alone. The majority of patients require no additional treatment.

Q: Are some patients at greater risk than others?

A: It is not possible to predict who will develop BIA-ALCL, and while the Australian Government reports a higher risk of BIA-ALCL in those patients with textured/polyurethane implants, the data is not yet well established. This risk remains far less than that other known risks, such as capsular contracture.

A: It has occurred in women who have breast implants for both cosmetic and reconstructive purposes.

A: BIA-ALCL has occurred in women with both saline and silicone implants.

Q: Should patients have their implants removed?

A: Neither the FDA nor the Australian Government’s report suggest additional screening or removal of implants for asymptomatic women.

Q: Should women with breast implants be screened for BIA-ALCL?

A: Expert opinion is that asymptomatic women without breast changes do not require more than routine follow-up. If a patient experiences a change in her breasts – especially if there is swelling or a lump – she should undergo examination and appropriate imaging, including ultrasound and fine needle aspiration of any peri-implant fluid.

Q: What causes BIA-ALCL?

A: ASPS, ASERF, the FDA, and the implant manufacturers are working proactively to study BIA-ALCL. To date, no specific causal factors have been identified. Implant texturing, bacteriologic contamination, and genetic factors have been implicated and are undergoing further study.

A: Bacteria have been identified within the lymphoma and around implants in affected breasts, and there is accumulating evidence that a long-term inflammatory response to the presence of these bacteria is one of the factors that may cause BIA-ALCL. Research is ongoing and cases are being monitored through the PROFILE registry.

A: Genetic factors may play a role. The Australia/New Zealand risk appears higher than other studies have indicated. Some geographic areas have reported very few cases. Ongoing data collection worldwide will help to determine whether or not there are any genetic propensities for this disease.

Q: Do ASAPS and ASPS recommend against the use of textured implants?

A: The available data does not support discontinuance of textured implants. The best practice is always for the physician to discuss with each patient the known risks and potential complications associated with any procedure. It is important for the patient and her doctor to frankly discuss all options available, and the risks involved.

A: Every plastic surgeon offers patients options regarding breast implants in terms of sizing, shape, and surface. Textured implants may offer advantages when placed subglandularly (lower risk of capsular contracture), and when an anatomically shaped implant is utilized (lower risk of malrotation). Depending on a particular patient’s needs, a textured implant may be preferable. The plastic surgeon must provide a frank and transparent discussion regarding the benefits and risks of implants, both smooth and textured. The patient must then make an informed decision, based upon her own assessment of her needs and the risks involved.

A: Every plastic surgeon needs to help each individual patient make her own decision about which implant she prefers in a fully transparent manner. This involves weighing any possible increased risks against the advantages offered by a particular type of implant. It is critical that the patient makes a fully informed decision following a full discussion of the risks and benefits.

Q: What does Dr. Sowder think of textured implants?

A: Geeze, I’m glad you asked.  I have never been a big fan of textured implants and have used them very infrequently over the years.  The main reason for this is that I do not use many anatomic (tear drop shaped) implants which are always textured.  I have found these implants, in my hands, to require more revision that smooth, round implants.  Also, and I have blogged about this many times, I don’t think anatomic implants make a difference in the vast majority of patients so there is not reason to use them.  Anatomic implants are textured so they “stick” and stay put and do not rotate or flip.  If a smooth round implant rotates or flips, it does not change the shape of the breast.  I consider myself lucky not to have many patients with textured implants out there.  I am a worry wart by nature.  If my current practice were heavy into textured anatomics, I would be questioning the wisdom of this at least until we know more about BIA-ALCL.  There are some plastic surgeons out there who are very evangelical about using anatomic implants (and often times paid con$ultant$ to implant manufacturers) and rather than say, “Whoa Bessie, let’s see how this all unfolds”, some of them are digging in and minimizing the risk of BIA-ALCL which seems to go up with every new study.  This sort of stuff makes me cranky.  One very difficult issue is that of textured tissue expanders used to stretch out the skin and muscle for implant based breast reconstruction.  All of the expanders are anatomic and thus need to be textured so they don’t rotate of flip. I no longer do breast reconstruction but if I did, I would still use textured expanders because there is no alternative.

Q: Have there been any deaths due to BIA-ALCL?

A: There have been 12 confirmed deaths, including 6 in the United States, attributed to BIA-ALCL since the disease was first reported nearly 20 years ago.

Q: What is the recommended clinical response to a patient presenting with symptoms that could be attributable to ALCL?

A:  As in all diseases, the first step is to establish a diagnosis.  Depending on the extent of the BIA-ALCL, treatment would always involve implant removal and total capsulectomy and, if indicated, chemotherapy.  The recent JAMA article reported over 90% of women who underwent proper therapy as having complete remission.

A: In July 2016, ASPS and ASAPS issued a joint “Tear Sheet” describing the recommended clinical protocol for patients presenting with symptoms that could be attributable to BI-ALCL. For a copy of the ASPS/ASAPS Tear Sheet please go to: Joint-ASPS-ASAPS Statement On Breast Implant-Associated ALCL

Access on the ASAPS website at: http://www.surgery.org/professionals

This protocol formed the framework for the international recommendations by the National Comprehensive Cancer Network (NCCN) for the diagnosis of BIA-ALCL and can be accessed at nccn.org.

Q: How is BIA-ALCL diagnosed?

A: If a woman develops swelling in an augmented breast, she should undergo an ultrasound scan. If fluid is detected, it should be drained and tested with CD30 immunohistochemistry to diagnose BIA-ALCL. Mammograms are not useful in diagnosing BIA-ALCL. In confirmed cases MRI and PET/CT scans may be performed to help stage the disease.

Q: How is organized plastic surgery working with the FDA to study BIA-ALCL?

A: The Plastic Surgery Foundation (PSF) created PROFILE (Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma, Etiology and Epidemiology) in 2012, a collaboration with the FDA. Any suspected or confirmed cases of BIA‐ALCL should be reported for inclusion in the PROFILE registry at ThePSF.org/PROFILE.

A: PROFILE is collecting data both retrospectively and prospectively on confirmed cases of BIA-ALCL.

A: The primary goal of PROFILE is to better understand the role of the breast implants in the etiology of BIA-ALCL. The research hopes to identify potential risk factors, diagnostic predictors, and the best ways to manage this disease. In addition to providing health care practitioners and patients with information about the diagnosis and treatment of ALCL, the confirmed cases will assist with further analytical epidemiological studies.

Q: Where can I find more information on BIA-ALCL?

A: Additional information and resources on BIA-ALCL are available online at www.plasticsurgery.org/alcl and by searching “ALCL” on RADAR.

Reporters seeking information or plastic surgeons contacted by a member of the media are encouraged to forward inquiries to Adam Ross, ASPS integrated communications manager at aross@plasticsurgery.org or 847-228-3361. ASAPS members are encouraged to contact Leigh Hope Fountain, ASAPS director of Public Relations, at leigh@surgery.org or 561-7917

 

Uncategorized

The Opioid Crisis and the Post Surgical Patient

December 11th, 2017 — 12:42pm

It seems that not a day goes by when we are not hearing more bad news about America’s opioid crisis.  And with good reason.  This crisis is ruining the lives of the abusers and those who love and depend on them.  A recent photo  spread in the New Yorker Magazine laid it all out in clear and agonizing black and white. So what is a surgical practice like mine doing to respond to this crisis?

Just about every operation I do causes a significant amount of postoperative pain for which I usually prescribe an opioid.  In the 26+ years I have been in practice, I have seen only a few patients who I felt were getting habituated to the medication I prescribed.  And in those cases, I take a straight forward:  “I am worried about your narcotic use” approach.  To my knowledge, I have not had a surgical patient become an addict. 

It is a fine line we have to walk between over prescribing and under prescribing.  Most patients are seen maybe 3 – 7 days after surgery for dressing changes, drain removal and general checking in.  We try to prescribe enough medication to last until that first post op appointment.  If a patient runs out of their narcotic pain medication, we cannot phone in a prescription.  The patient or their caregiver must come to the office to obtain a “hard copy”.  This can be a real burden for the patient.  Often we will write an additional prescription for the patient to fill in the event they run out prior to an office visit.  We emphasize that if the prescription is not used, it should be destroyed.  Likewise, all unused medication does not belong in the medicine cabinet “just in case”.  It should be destroyed or returned to the pharmacy for proper disposal.  There is evidence that diversion of narcotics is a driver in addiction.

We also try to help with pain control with non-opioids.  Almost all tummy tucks get an On-Q pain pump that helps with postoperative discomfort for the first three days after surgery.  We use instillation and injection of long acting local anesthetics to take the edge off of surgical pain.  And once a patient is about 5 days out from surgery, we do out best to get them onto an NSAID and off their prescription pain medication.

Research has shown that it is when opioids are used for chronic pain conditions, patients are much more likely to fall into habituation and addiction.  Opioid use for acute pain (like post operative pain) usually is temporary and most often discontinued by the patient with very few problems.  Most of my patients do not like the way they feel on narcotics and are anxious to get off.  An occasional patient really likes that loopy and foggy feeling that narcotics provide and those are the ones that we worry about.  Again, I take a straight forward approach “You like this medication way to much.  Time to get onto an NSAID.”

On thing that has really changed with the new laws regarding phoning in narcotic prescriptions is the steep decline in bogus phone calls to the doctor on call from drug seeking individuals.  When I was in a large call group years ago, it was not unusual to get one or more of these bogus calls on a weekend.  These calls could be very troubling for the doctor on call because it was often difficult to sort out a legitimate patient and a bogus caller.  What is worse:  phoning in a script for Vicodin to be abused or diverted or not providing relief to a postoperative patient?

One thing everyone can do to help fight this crisis is to take a look in your medicine cabinet.  Are there unused prescription pain pills in there?  If so, take them to our nearest pharmacy for disposal.

Thanks for reading.  Dr. Lisa Lynn Sowder

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