Perioperative management of cosmetic liposuction

Recent qualms about the safety of aesthetic lipoplasty may be attributable more to support system flaws than to technical process deficiencies. The authors here focus on perfunctory patient monitoring when sedative or analgesic drugs are given, cavalier infiltration of mega-dose lidocaine, cursory intraoperative patient observation by team members with conflicting responsibilities, anesthesia providers unfamiliar with the unique surgical physiology of liposuction, hurried-discharge policies that virtually ignore the residual depressant effects of sedatives and analgesics, and compressive dressings that impair postoperative chest-wall expansion and venous return. Whereas pulmonary embolism remains the leading process cause of morbidity from liposuction, complications from austere resource allocation to dedicated patient monitoring should be largely preventable. Not all lipoplasties require an anesthesia provider but-when heavy sedation, mega-dose lidocaine, or both, are projected-a trained team member dedicated exclusively to patient safety and comfort should be a minimum patient care standard. The potential role of lidocaine cardiotoxicity in tumescent anesthesia is widely underappreciated and that of hypothermia goes mostly unrecognized. These, plus largely preventable or potentially correctable perioperative events such as pulmonary edema, fluid imbalance, or improperly administered sedative and analgesic drugs, demand upgrading and expansion of monitoring, resuscitative, and recuperative facilities in physician offices. In fact, ASPS guidelines urge that anesthesia services be engaged for dedicated patient care whenever "major" liposuction or conscious sedation is projected, because liposuction is neither as benign nor as simple a procedure as heretofore reputed. To assess objectively the operative and anesthetic risk of obesity, document body mass index for the preoperative record; morbid obesity (body mass index >/= 35.0), for instance, is a known risk multiplier for sedatives and analgesics. Other system issues such as the dynamic profile of high-dose lidocaine pharmacokinetics, the deportation of fat globules in the bloodstream, and the incidence of intraoperative hypothermia remain as unresolved topics for interdisciplinary, multi-institutional clinical research.     

The key to long-term success in liposuction: a guide for plastic surgeons and patients

Patients need to have realistic expectations for a long-term successful body contour result. There are four key elements for long-term successful improvement in body contour, and the patient is responsible for the first three: exercise, a proper diet, and other positive lifestyle changes; and successful body contouring. An extensive survey requesting information about the procedures, areas of liposuction, lifestyle habits, and satisfaction was mailed to 600 patients who had liposuction surgery performed between 1999 and 2003. One hundred and eight surveys were undeliverable and 209 completed surveys were returned (34.8 percent of 600 mailed surveys and 42.5 percent of 492 delivered surveys). Data were analyzed by a binary logistic regression with backward elimination. Weight gain (versus no weight gain) was used as the dependent variable. The results showed that regardless of whether the patient did or did not gain weight, both groups reported being very satisfied (30 percent and 48 percent, respectively) or satisfied (43 percent and 34 percent, respectively) with their procedure. Among the weight gain patients, 72 percent would still have the procedure again, compared with 82 percent of responders who did not gain weight. When asked if they would recommend the procedure to family or friends, 90 percent of responders who did not gain weight would recommend the procedure whereas only 74 percent of responders who did gain weight would recommend the procedure (p < 0.001). Among those patients who gained weight, only 29 percent thought their appearance was excellent or good (compared with 79 percent of those who did not gain weight). Among the 57 percent of patients who did not gain weight, 35 percent report exercising more postoperatively (compared with only 10 percent in the weight gain group, p = 0.002) and 50 percent report eating a healthier diet (22 percent in the weight gain group report eating a healthier diet, p = 0.002). In the weight gain group, 67 percent report no change in their diet regimen and only 17 percent thought their productivity increased (compared with 25 percent among the no weight gain group, p = 0.002). Successful body contouring surgery requires a patient to embrace positive lifestyle habits. The results of this survey have been used to create a quantitative decision-making framework or a "road map" for patients and plastic surgeons to use for navigating toward successful long-term results.     

Care of maxillofacial injuries: survey of plastic surgeons.

The purpose of this survey was to evaluate the current trends in the care of facial trauma. Data were obtained through the responses of a survey mailed to all those members and candidates listed in the 1989 American Society of Plastic and Reconstructive Surgeons Directory. A total of 2777 questionnaires were sent, with 1113 (40 percent) returned by means of a self-addressed envelope. Demographic results show that over 70 percent of the treating plastic surgeons fall within the age range 30 to 50 years. Although significant advances have occurred, treatment goals have remained unchanged. These center around the principles of accurate reduction and precise stabilization of fracture segments. The results of this survey reveal that a number of acceptable techniques were employed in the surgical repair of mandibular and zygomatic complex fractures. In the care of Le Fort III fractures, 59 percent of the respondents preferred the use of miniplates and screws for stabilization. Only 26.8 percent believed that facial fracture repair should be performed within the initial 24 hours. With frontal sinus fractures, the vast majority of plastic surgeons (82.1 percent) obtained a neurosurgical consultation. When the posterior wall was involved, 45.6 percent favored removal of the sinus mucosa, 29.7 percent obliterated the frontal sinus with a variety of autogenous materials, while 20.5 percent preferred cranialization. In summary, this survey shows a wide variation in the practice of facial fracture management within the plastic surgical community.     

A review of psychosocial outcomes for patients seeking cosmetic surgery

The authors reviewed the literature on psychological and psychosocial outcomes for individuals undergoing cosmetic surgery, to address whether elective cosmetic procedures improve psychological well-being and psychosocial functioning and whether there are identifiable predictors of an unsatisfactory psychological outcome. They conducted a search of appropriate computerized databases for studies that evaluated psychological and psychosocial status both before and after elective cosmetic surgery. They identified 37 relevant studies of varying cosmetic procedures that utilized disparate methodologies. Overall, patients appeared generally satisfied with the outcome of their procedures, although some exhibited transient and some exhibited longer-lasting psychological disturbance. Factors associated with poor psychosocial outcome included being young, being male, having unrealistic expectations of the procedure, previous unsatisfactory cosmetic surgery, minimal deformity, motivation based on relationship issues, and a history of depression, anxiety, or personality disorder. Body dysmorphic disorder was also recognized by some studies as a predictor of poor outcome, a finding reinforced by reference to the psychiatric literature. The authors conclude that although most people appear satisfied with the outcome of cosmetic surgical procedures, some are not, and attempts should be made to screen for such individuals in cosmetic surgery settings.     

The financial environment of aesthetic surgery: results of a survey of plastic surgeons

To gather information about aesthetic surgery's current practice structures, competitive environment, patient price sensitivity, and marketing and practice development requirements, a two-page survey was developed and mailed to all 1180 members of the American Society for Aesthetic Plastic Surgery. A total of 632 surveys were returned (response rate of 54.5 percent). Most aesthetic plastic surgeons said they were in solo practice (63.3 percent). More than two-thirds described the marketplace as "very competitive," with 59 percent reporting 25 or more surgeons offering aesthetic surgery in their area. They estimated their patients' average income at $62,800. Nearly all plastic surgeons labeled their patients as "moderately price sensitive" (62.3 percent) or "very price sensitive" (30.6 percent). Similarly, 23.2 percent estimated that they had lost 20 or more patients within the last year for reasons of price. Practice development and marketing efforts represented an average of 7.3 percent of plastic surgeons' working time. Parameters associated with a high percentage of time devoted to these activities were solo practice, percentage of revenue from aesthetic surgery greater than 50 percent, a practice environment designation of moderately or very competitive, and ten or more area surgeons offering aesthetic surgery (p < 0.05). High patient income led to only slight decreases in price sensitivity and did not significantly reduce the amount of time spent on marketing and practice development. Although the rest of the healthcare industry has undergone a period of consolidation, aesthetic surgeons have been able to resist these changes. The results of this survey suggest that the fragmented nature of the aesthetic surgery industry is associated with additional burdens on plastic surgeons. As the aesthetic surgery market becomes more competitive, plastic surgeons may benefit from consolidation to reduce costs and maximize efficiency.     

Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002

The purpose of this survey was to assess the current trends in breast reduction techniques and to compare satisfaction rates and complications associated with traditional incision and limited incision techniques. In September of 2002, a breast reduction survey was sent to 1500 members of the American Society for Aesthetic Plastic Surgery; 554 of the members returned the survey. Questions elicited categorical answers, and the data were evaluated using the chi-square test and the comparison of two proportions. The results showed that 56 percent of the respondents use only the inferior pedicle and Wise pattern techniques, whereas 6.9 percent of the respondents use only the limited incision techniques. Physician satisfaction was rated as 4 on a scale of 1 (unsatisfied) to 5 (very satisfied) for both the limited incision and traditional incision groups. Patient satisfaction was rated as 4 for the limited incision group and as 5 for the traditional incision group. This difference in patient satisfaction per surgeon was statistically significant (p < 0.05). The traditional group reported a lower complication rate than did the limited incision group (p < 0.05). The most frequent complications for the traditional incision group were compared with those of the limited incision group. Practice profiles, liposuction, and opinions regarding future changes in breast surgery were also analyzed. The majority of surgeons reported that they did not anticipate changing their practices to accommodate advances in limited incision techniques; however, 89 percent reported that the new limited incision techniques and liposuction are trends that are here to stay.     

Seasonality of birth: two findings from the decennial census

The enigmatic seasonality of births in the US has been analyzed extensively, but gaps in the knowledge of this phenomenon exist along dimensions not accessed by the national vital registration system. Live births in the US have for some time followed a pattern of spring trough and summer peak--at least since the initiation of the national birth registration system in 1933. The pattern is known to be more pronounced for the South than for other regions and for blacks than for whites. In this study it has been shown that this pattern existed as far back as the 1890's, and currently is more pronounced for lower than for higher socioeconomic groups. These findings come from an analysis of census population data, rather than vital registration data. In this way census data have been used in an innovative way to address 2 aspects of the phenomenon which had heretofore not been adequately treated.     

Seasonality of birth: Two findings from the decennial census

Abstract

Two results on the seasonality of birth phenomenon are derived from tabulations of 1980 census data: first, that the familiar pattern of spring trough and summer peak prevailed in the decades before the establishment of a national birth registration data system; second, that the seasonal pattern is most pronounced for the lower socioeconomic group.     

Microbial survey of shared-use cosmetic test kits available to the public

Summary Some people like to try cosmetics before purchasing them. With repeated use by different customers, however, the tester kits provided by many retail outlets can become potential vectors of microbial pathogens. A survey was conducted to assess the health risk from bacteria found on shared-use cosmetics. A total of 3027 shared-use cosmetic product samples were collected from 171 retail establishments throughout the contiguous United States. Eye, face and lip cosmetics were tested within situ nondestructive swabbing and the use of the Transette 3R Modified Amies Charcoal Culture and Transport System. Bacteria were isolated from about 50% of the items for all three categories. Semiquantitatively-estimated mean densities were 2288, 1685 and 1088 CFU g^–1 for eye, face and lip products, respectively. Ranges for all categories were 0–15⁵ CFU g^–1. About 5% of the items had bacterial counts above 5000 CFU g^–1 (eye products) or 10 000 CFU g^–1 (other products). More than 60% of isolates were typical of microflora from human skin; the remainder were environmental microbes. About 60% of the isolates were Gram-positive cocci:Staphylococcus spp. (especiallyS. epidermidis) andMicrococcus spp. The Gram-negative pathogenPseudomonas aeruginosa constituted 0.07% of the isolates. The survey results suggest that the preservation systems of some of the cosmetics failed under excessive use (abuse), and indicated a potential for microbiological safety problems with shared-use consmetics.