Fatal outcomes from liposuction: census survey of cosmetic surgeons

Troubling reports of adverse outcomes after liposuction prompted a census survey of aesthetic plastic surgeons. All 1200 actively practicing North American board-certified ASAPS members were polled by facsimile, then mail, regarding deaths after liposuction. Patient initials together with case summaries precluded data replication yet assured patient anonymity and preserved surgeon privacy. Incomplete returns or ambiguous findings were authenticated, where feasible, by direct follow-up. Total number of lipoplasties performed by plastic surgeons was interpolated from the ASPRS procedure database for the survey time frame of 1994 to mid-1998. Lacking reliable annual case volume estimates, deaths from lipoplasties performed by non-ABPS surgeons were excluded from the actual mortality rate computation but were included in cause-of-death ranking statistics. Responding aesthetic plastic surgeons (917 of 1200) reported 95 uniquely authenticated fatalities in 496,245 lipoplasties. In this census survey, the mortality rate computed to 1 in 5224, or 19.1 per 100,000. A virtually identical 20.3 per 100,000 mortality rate was obtained in a 1997 random survey commissioned by the parent society. Pulmonary thromboembolism remains as the major killer (23.4+/-2.6 percent); lacking consistent medical examiners' toxicology data, the putative role of high-dose lidocaine cardiotoxicity could not be ascertained. Where so stated, many deaths occurred during the first night after discharge home; prudence suggests vigilant observation for residual "hangover" from sedative/anesthetic drugs after lengthy procedures. Taken together, these two independent surveys peg the late 1990s mortality rate from liposuction at about 20 per 100,000, or 1 in every 5000 procedures. Set beside the 16.4 per 100,000 fatality rates of U.S. motor vehicle accidents, liposuction is not an altogether benign procedure. We do not have comparable mortality data for lipoplasties performed by non-ABPS-certified physicians.     

Blood loss in major liposuction procedures: a comparison study using suction-assisted versus ultrasonically assisted lipoplasty.

The blood loss that accompanies liposuction procedures has always been a concern. Tumescent injection of the targeted area of liposuction with dilute lidocaine and epinephrine solution has minimized intraoperative blood loss. Proponents of a newer ultrasonically assisted lipoplasty technique have claimed many benefits over traditional suction-assisted lipoplasty. However, few quantitative data are available on the intraoperative blood loss and the significance of postoperative anemia using the ultrasonic method. A prospective clinical observational design was used to investigate 38 patients undergoing suction-assisted lipoplasty and 37 patients undergoing ultrasound-assisted lipoplasty in whom the liposuction aspirate was expected to be more than 1000 ml. These patients were investigated with preoperative measurement of hemoglobin, platelet count, prothrombin time, partial thromboplastin time, and postoperative measurement of hemoglobin on the seventh postoperative day. In addition, hemoglobin concentration and whole blood volume were calculated from the infranatant portion of the liposuction aspirate. The mean +/- SD volume of the liposuction aspirate was 2901 +/- 1471 ml for suction-assisted compared with 2741 +/- 1086 ml for ultrasound-assisted lipoplasty. The mean +/- SD of whole blood volume in liposuction aspirate per case was 36 +/- 50.82 ml for suction-assisted lipoplasty and 36 +/- 28.62 ml for ultrasound-assisted lipoplasty. The mean +/- SD of the preoperative hemoglobin concentration was 13.93 +/- 0.99 g/dl for suction-assisted lipoplasty and 14.05 +/- 1.16 g/dl for ultrasound-assisted lipoplasty, whereas the mean +/- SD of the postoperative hemoglobin concentration was 13 +/- 1.42 g/dl for suction-assisted lipoplasty and 13.05 +/- 1.32 g/dl for ultrasound-assisted lipoplasty. The mean decrease in hemoglobin on the seventh postoperative day was 0.93 +/- 0.92 g/dl for suction-assisted lipoplasty and 1 +/- 0.64 g/dl for ultrasound-assisted lipoplasty. The volume of whole blood loss was estimated to be 12.4 ml in each 1000 ml of liposuction aspirate when using suction-assisted lipoplasty versus 13.1 ml when using ultrasound-assisted lipoplasty. All procedures were done under general anesthesia, and patients were discharged home on the same day. No blood transfusion was required. This study shows that blood loss using the ultrasonic technique is slightly higher, though insignificant, than when using suction. However, this study did not demonstrate a difference in the postoperative hemoglobin decrease between the two techniques.     

Comparative lipoplasty analysis of in vivo-treated adipose tissue

A comparative histologic and chemical analysis was undertaken of adipose tissue treated in vivo with traditional, ultrasound-assisted, and external ultrasound-assisted lipoplasty. A series of six healthy women undergoing elective liposuction according to the superwet technique using a 1:1 infiltration ratio with the estimated quantity of fat to be removed was included in the study. Four separate regions on each patient were treated independently in vivo with traditional liposuction, internal ultrasound-assisted liposuction, or external ultrasound-assisted liposuction for 7 minutes. External massage was used as a control. Four separate specimens of adipose tissue from each patient were assessed for cellular disruption using blinded histologic evaluation. The remainder of tissue was centrifuged to separate the aqueous phase from the cellular components and then spectrophotometrically analyzed for creatinine kinase and glycerol 3-phosphate dehydrogenase activity as markers of cellular disruption. Histologic analysis confirmed 70 to 90 percent cellular disruption with internal ultrasound-assisted liposuction. Suction-assisted and external ultrasound-assisted liposuction showed 5 to 25 percent disruption, whereas massage controls showed only 5 percent. Only internal ultrasound-assisted liposuction showed 5 to 20 percent thermal liquefaction. Absorbance analysis showed creatine kinase activity (sigma units) greatest in ultrasound-exposed tissue. Both external and internal ultrasound-assisted liposuction gave creatine kinase levels 28 to 33 percent greater than suction-assisted liposuction, which varied only 10 percent from controls. Glycerol 3-phosphate dehydrogenase activity was 44 percent greater for internal ultrasound-assisted liposuction than that detected with suction-assisted liposuction. Glycerol 3-phosphate dehydrogenase activity with external ultrasound-assisted liposuction and massage did not vary much from each other, at only 14 percent and 11 percent activity compared with internal ultrasound-assisted liposuction, respectively. Histologic and enzyme analysis of the different types of liposuction and their effect on adipocyte cellular disruption revealed no significant effect of external ultrasound or massage on the adipocytes. Further experimental studies are necessary to evaluate the role and efficacy of alternative techniques for body contouring.     

Incidence of pyometra in Swedish insured cats

Pyometra is a clinically relevant problem in intact female cats and dogs. The etiology is similar in both animal species, with the disease caused by bacterial infection of a progesterone-sensitized uterus. Here, we studied pyometra in cats with the aim to describe the incidence and probability of developing pyometra based on age and breed. The data used were reimbursed claims for veterinary care insurance or life insurance claims or both in cats insured in a Swedish insurance database from 1999 to 2006. The mean incidence rate (IR) for pyometra was about 17 cats per 10,000 cat years at risk (CYAR). Cats with pyometra were diagnosed at a median age of 4 years and a significant breed effect was observed. The breed with the highest IR (433 cats per 10,000 CYAR) was the Sphynx, and other breeds with IR over 60 cats per 10,000 CYAR were Siberian cat, Ocicat, Korat, Siamese, Ragdoll, Maine coon, and Bengal. Pyometra was more commonly diagnosed with increasing age, with a marked increase in cats older than 7 years. The mean case fatality rate in all cats was 5.7%, which is slightly higher than corresponding reports in dogs of 3% to 4%. Geographical location (urban or rural) did not affect the risk of developing the disease. The present study provides information of incidence and probability of developing pyometra based on age, breed, and urban or rural geographical location. These data may be useful for designing cat breeding programs in high-risk breeds and for future studies of the genetic background of the disease.     

Profile of Canadian physicians: results of the 1990 Physician Resource Questionnaire.

OBJECTIVE: To determine the supply, mix and distribution of physicians in Canada and to compare data with those of the 1982 and 1986 physician surveys. DESIGN: National census mail survey. SETTING: Canada. PARTICIPANTS: All physicians licensed to practise medicine in Canada, excluding interns and residents. A total of 52,422 questionnaires were mailed, of which 771 were ineligible. There were 38,313 valid responses (response rate 74.2%). MAIN OUTCOME MEASURES: Activity status, workload, specialty certification, practice setting and demographic profiles. MAIN RESULTS: A total of 88.7% of the respondents were active physicians; 19.4% were women, compared with 16.8% in 1986. Physicians reported working on average 4.1 fewer hours per week in total activities than in 1986 and 5.7 fewer hours per week than in 1982. As was found in 1982, about 50% of active physicians were certified specialists; 30% of specialists and 21% of general/family practitioners were 55 years of age or more. Approximately 11% of active physicians were in rural practice, as was reported in 1986. Similar proportions of foreign graduates and Canadian graduates were located in rural areas (10.9% and 11.4% respectively). CONCLUSIONS: Factors such as aging and retirement will affect specific specialty groups (e.g., general surgery and obstetrics/gynecology) in the near future. Specialty groups must address the issue of the future supply of physicians and the demand for their services when developing targeted needs within their specialties. The increasing proportion of women in medicine is changing the specialty mix and practice profiles of physicians as a whole. The issues associated with the recruitment and retention of physicians in rural areas remain complex.     

The use of intraoperative grid pattern markings in lipoplasty

Intraoperative grid pattern markings have been used in the performance of liposuction. Grid pattern markings include series of longitudinal and transverse lines to delineate various anatomical boundaries and landmarks, including the midline, lateral line, and medial line. The markings are superimposed on the customary preoperative markings and divide broad or circumferential body surfaces into smaller subunits for liposuction. Grid pattern markings are applied to areas such as the anterior thighs, medial thighs, entire abdomen, flanks, back, arms, buttocks, calves, and ankles; they are not applied to smaller, less curved areas. Eighty-two consecutive patients underwent lipoplasty in 562 areas of the body. The revision rate for postliposuction contour irregularities was 4.0 percent (nine of 224 areas) where grid pattern markings were used; one area had an indentation type of contour irregularity and required autologous fat grafting. The revision rate was 1.5 percent (five of 328 areas) where grid pattern markings were not used; two areas in one patient had indentation-type contour irregularities and required autologous fat grafting. All remaining areas requiring revision had protuberant-type contour irregularities and responded to additional liposuction only. The use of grid pattern markings is associated with a low incidence of serious contour-related complications.     

Policy Design of Multi-Year Crop Insurance Contracts with Partial Payments

Current crop insurance is designed to mitigate monetary fluctuations resulting from yield losses for a specific year. However, yield realization tendency can vary from year to year and may depend on the correlation of yield realizations across years. When the current single-year Yield Protection (YP) and Area Risk Protection Insurance (ARPI) contracts are extended to multiple periods, actuarially fair premium rate is expected to decrease as poor yield realizations in a year can be offset by another year’s better yield realizations. In this study, we first use simulations to demonstrate how significant premium savings are possible when coverage is based on the sum of yields across years rather than on a year-by-year basis. We then describe the design of a multi-year framework of crop insurance and model the insurance using a copula approach. Insurance terms are extended to more than a year and the premium, liability, and indemnity are determined by a multi-year term. Moreover, partial payment is provided at the end of each term to offset the possibility of significant loss in a single term. County-level data obtained from the U.S. Department of Agriculture are used to demonstrate the implementations of the proposed multi-year crop insurance. The proposed multi-year plan would benefit farmers by offering insurance guarantees across years for significantly lower costs.     

Type of Practice of Physicians in California,Report of the Bureau of Research and Planning

The total number of non-federal^* physicians in California rose from 23,065 in mid-1959 to 26,271 in January, 1962, an 11.3 per cent increase. The proportion of physicians in private active practice remained almost constant during this period.A significant rise, both in number and proportionally, took place in the full-time specialty category, offset by losses in the general practice-part-time specialty group. While specialists increased by over 30 per cent, general practitioners, who made up 31.7 per cent of all non-federal physicians in 1959, were only 24.7 per cent of the total in early 1962.     

Mortality among doctors in different occupations.

A total of 20540 male doctors who replied to a questionnaire on their smoking habits that was sent to them on 1 November 1951, and who were aged 35 years and over, were classified according to their occupation as listed in the Medical Directory for 1952 and followed up until 1 November 1971. Examination of the mortality rates in 11 occupational groups showed gross heterogeneity for smoking-related diseases but not for all other diseases grouped together. On average, general practitioners smoked 37% more cigarettes than did hospital physicians and surgeons and the overall death rates among general practitioners were about 23% higher than among physicians and surgeons of similar ages. This excess death rate was chiefly accounted for by a 38% excess mortality from smoking-related diseases such as lung cancer, chronic bronchitis, and ischaemic and pulmonary heart disease. The few other statistically significant associations between occupation and disease were thought to be due either to chance or to the effect of the disease on the choice of specialty.     

Medical malpractice in perspective. I--The American experience.

Concern over the possibility of an American style medical malpractice "crisis" in the United Kingdom has recently been voiced by members of both medical and legal professions. The validity of such fears is examined by reviewing the conditions that have given rise to the current American difficulties. It is argued that the rise in malpractice insurance premiums and associated restrictions in availability should be seen against the background of underwriting problems specific to medical liability in conjunction with a general decline in reinsurance cover. The evidence in relation to the clinical and resource implications of malpractice is analysed. In particular, arguments that increased litigation has influenced the practice of "defensive" medicine and the choice of specialty are critically examined. Medical malpractice claims and insurance are only part of a professional environment which is undergoing dramatic social and economic changes, many of which seem more plausible candidates to be treated as important influences on the nature and organisation of health care in the United States.     

Gender-based differences in physician payments within the fee-for-service system in Ontario: a retrospective,cross-sectional study

Background:Differences in physician income by gender have been described in numerous jurisdictions, but few studies have looked at a Canadian cohort with adjustment for confounders. In this study, we aimed to understand differences in fee-for-service payments to men and women physicians in Ontario.Methods:We conducted a cross-sectional analysis of all Ontario physicians who submitted claims to the Ontario Health Insurance Plan (OHIP) in 2017. For each physician, we gathered demographic information from the College of Physicians and Surgeons of Ontario registry. We compared differences in physician claims between men and women in the entire cohort and within each specialty using multivariable linear regressions, controlling for length of practice, specialty and practice location.Results:We identified a cohort of 30 167 physicians who submitted claims to OHIP in 2017, including 17 992 men and 12 175 women. When controlling for confounding variables in a linear mixed-effects regression model, annual physician claims were $93 930 (95% confidence interval $88 434 to $99 431) higher for men than for women. Women claimed 74% as much as men when adjusting for covariates. This discrepancy was present in nearly all specialty categories. Men claimed more than women throughout their careers, with the greatest gap 10–15 years into practice.Interpretation:We found a gender gap in fee-for-service claims in Ontario, with women claiming less than men overall and in nearly every specialty. Further work is required to understand the root causes of the gender pay gap.

A gender pay gap in physician incomes has been described across numerous jurisdictions.¹ Previous analyses have found income differences between women and men in the general physician population, among academic physicians and among physicians within the same specialty, ^2–8 and when controlling for years of experience, hours worked, geographic location, race and practice type.^9–13Although the difference in physician income between women and men is well described in the United States, fewer studies have looked at a Canadian cohort. An analysis of surgeons in Ontario found that female surgeons earned less per hour spent operating than male surgeons, and suggested that female physicians were more likely to perform less lucrative procedures than male physicians.¹⁴ A recent report released by the Ontario Medical Association highlighted income disparity between men and women physicians in Ontario, but did not provide a detailed breakdown by specialty.¹⁵ Transparent and detailed reporting on gender differences in physician payments can provide data to guide advocacy for greater pay equity.In this study, we aimed to describe payments to physicians across the province of Ontario by gender when controlling for specialty choice, career stage and physician demographics.     

External ultrasonic lipoplasty: an effective method of fat removal and skin shrinkage

External ultrasonic lipoplasty is an effective method for the removal of localized fat and the fat due to moderate obesity. The ultrasound is externally applied and transmitted through the skin surface. The acoustic waves are selectively absorbed by previously injected tumescent fluid and fat. It is the combination of this acoustic wave and ultrasound-induced fluid streaming that facilitates fat removal. Multiple, 2.5- to 3.7-mm incisions are made, through which standard thin (2.3 to 3.5 mm) suction lipectomy cannulae are used to aspirate the emulsified fat and oil. A major advantage of this procedure is that superficial subdermal liposuction can be used safely, which enhances the thoroughness of fat removal and the contraction of the overlying skin. A total of 160 consecutive patients successfully underwent this procedure. Recovery was rapid, and patients returned to full activities within 24 to 48 hours. The skin remained soft, with minimal to no bruising throughout the entire postoperative period. The problems seen with internal ultrasonic liposuction, such as end hits and skin burns, were avoided. The large incisions required for internal ultrasound liposuction were not necessary. Previous models of externally applied ultrasound support current observations of the safety of external ultrasound lipoplasty. Only one small seroma was seen. External ultrasound lipoplasty is a safe, effective, and low-cost method of ultrasound-assisted removal of localized fat and the fat due to moderate obesity. Physician and patient satisfaction is high.     

对医保定点医疗机构支付方式改革的思考

医保对定点医疗机构支付方式改革势在必行,应由传统的被动支付向管理型支付方向发展。在需方对医疗机构支付方式上,应确定与参保对象承受能力相适应的费用分担比例,同时组合应用多种支付方式;在医保对医疗机构支付方式上,应由后付制转向预付制、由单一的支付方式转向混合型支付方式。支付方式改革要辅之以加强对医疗机构的监管、加快卫生信息化建设、建立医保谈判机制和注重配套政策支撑等。     

Physician communication skills and malpractice claims. A complex relationship.

We assessed the relationship between patients'' opinions about their physicians'' communication skills and the physician''s history of medical malpractice claims. The sample consisted of 107 physicians and 2,030 of their patients who had had an operation or a delivery. Although patients tended to give their physicians favorable ratings, they were least satisfied with the amount of explanations they received. Patients gave higher ratings to general surgeons and obstetrician-gynecologists and poorer ratings to orthopedists and anesthesiologists. Women and better-educated patients gave higher ratings on explanations and communication to physicians with fewer claims. Men and patients with less education, however, gave higher ratings on these dimensions to physicians with more claims. These findings suggest the need for physicians to tailor their communications to a patient''s individual needs. Improved communication between physicians and patients may result in fewer nonmeritorious malpractice claims while leading to less costly resolution of meritorious claims.     

Cancer genetics evaluation: barriers to and improvements for referral

Despite the availability of cancer susceptibility testing, little information exists regarding physicians' selection and referral of eligible patients. This study provides insight into whom, why, and when physicians refer for cancer genetics evaluation, as well as their comfort level within this role. Eighty-two physicians (51 primary care, 15 gynecology, 11 surgery and 5 oncology) completed a survey (response rate: 34%) regarding cancer genetics referral practices. Of these, 59% reported an awareness of the hospital's cancer genetics program. Program awareness was greater among oncologists, surgeons, and gynecologists than among primary care physicians (p < 0.0001). Patients were referred for enhanced risk assessment (88%), improved medical management (85%), and concern for family members (83%). Patient eligibility was based on family cancer history (96%), patient cancer history (83%), and patient request (73%). Patients were not referred mainly due to patient disinterest (54%) or physician concern about either insurance coverage (44%) or insurance discrimination (31%). Primary care physicians were less comfortable with identifying patients for referral (p < 0.001) and with discussing genetics (p < 0.002) than specialists. The largest barriers to referral were lack of program awareness and limited knowledge regarding patient eligibility, improved insurance coverage, and antidiscrimination legislation. Physician-targeted marketing and education may improve the referral process.     

Large-volume circumferential liposuction with tumescent technique: a sure and viable procedure.

During a 4-year period, 152 female and 9 male patients underwent large-volume liposuction, with ages ranging from 19 to 65 years (mean of 36 years), with a weight previous to surgery between 57 and 126 kg (mean of 72 kg). Tumescent liposuction was done simultaneously by two surgeons in several corporal areas according to the necessities of each case. In 28 patients (17 percent), 500 ml of whole blood was required previous to the surgery by self donation. By means of liposuction, volumes between 5 and 22.3 liters (mean of 8.7 liters) were obtained with an average relation of 860 cc of fat for 140 cc of liquid. The reduction of hemoglobin and hematocrit at 1 week after surgery was of 3.8 g and 12 percent, respectively. The weight after surgery during the patient's follow-up varied from 54 to 111 kg, with an average of 66 kg. Major complications were not presented. Minor complications consisted of two superficial cutaneous necroses (1.2 percent) and 18 seromas (11.2 percent), which were drained without leaving sequelae; 24 patients (14.9 percent) presented postsurgical palpable irregularities, visible in only 8 patients (5 percent); 148 patients (92 percent) expressed important satisfaction with the results of the surgery, with the remaining 13 (8 percent) expressing some disagreement due to persistent irregularities. These complications had a direct relationship to some factors of the surgical technique and some characteristics of the patients. The amount of fat liposuctioned, the ideal height-weight relationship of the patient, the diameter of the cannulas used, and the experience acquired during the time were the most important factors that were associated with the complications. Based on these results, we concluded that large-volume circumferential liposuction with tumescent technique is a viable and sure alternative to achieve improvement of the body contour and weight loss.     

Workmen's compensation; emphasis on rehabilitation

Since the first law was enacted in 1911 major emphasis has been placed on monetary satisfaction of liability with insufficient attention to rehabilitation of the occupationally disabled. An effective workmen's compensation program must have three basic goals: (1) Rehabilitation of the occupationally disabled; (2) assured, prompt, and adequate indemnity for the occupationally disabled or their survivors; and (3) minimal costs to employers and society commensurate with the first two goals. It is suggested that the medical societies of each state provide a broadly representative committee to advise the administrative agency on medical policies and practices. This committee would prepare registers of all physicians in each locality who are willing and qualified to accept calls for service to injured employees, would mediate complaints originating with the employee, the employer, the insurance carrier or the administrative agency, and would cooperate with the administrative agency in educational programs for all concerned. It is the physician's responsibility to help the administrative agency in shifting the emphasis from indemnity to rehabilitation. The disabled employee is entitled to all services available to restore him to an earning capacity.     

The Canadian general internist: education and future role.

Available manpower data indicate that for the forseeable future there will be a continuing requirement in Canada for specialists in general internal medicine. While these specialists will be located predominantly in community hospitals, they will also be needed in university medical centres. The major roles of the general internist will be (a) to provide consultative service to primary care physicians and to other specialists, (b) to provide continuing care to patients with complex serious illness and (c) to participate in intensive care, particularly in community hospitals. Therefore training programs in this specialty must provide adequate experience in consultative medicine in both university and community hospitals, an opportunity to follow up patients with chronic serious illness over long periods, and experience in a variety of intensive care settings including surgical intensive care units. In some university departments the organization and supervision of training programs in this discipline have been carried out by a division of internal medicine that has equal status with other specialty divisions within the department. This seems to have been a salutory development.     

Fat liquefaction: effect of low-level laser energy on adipose tissue

Low-level laser energy has been increasingly used in the treatment of a broad range of conditions and has improved wound healing, reduced edema, and relieved pain of various etiologies. This study examined whether 635-nm low-level lasers had an effect on adipose tissue in vivo and the procedural implementation of lipoplasty/liposuction techniques. The experiment investigated the effect of 635-nm, 10-mW diode laser radiation with exclusive energy dispersing optics. Total energy values of 1.2 J/cm(2), 2.4 J/cm(2), and 3.6 J/cm(2) were applied on human adipose tissue taken from lipectomy samples of 12 healthy women. The tissue samples were irradiated for 0, 2, 4, and 6 minutes with and without tumescent solution and were studied using the protocols of transmission electron microscopy and scanning electron microscopy. Nonirradiated tissue samples were taken for reference. More than 180 images were recorded and professionally evaluated. All microscopic results showed that without laser exposure the normal adipose tissue appeared as a grape-shaped node. After 4 minutes of laser exposure, 80 percent of the fat was released from the adipose cells; at 6 minutes of laser exposure, 99 percent of the fat was released from the adipocyte. The released fat was collected in the interstitial space. Transmission electron microscopic images of the adipose tissue taken at x60,000 showed a transitory pore and complete deflation of the adipocytes. The low-level laser energy affected the adipose cell by causing a transitory pore in the cell membrane to open, which permitted the fat content to go from inside to outside the cell. The cells in the interstitial space and the capillaries remained intact. Low-level laser-assisted lipoplasty has a significant impact on the procedural implementation of lipoplasty techniques.