Botulinum-A toxin treatment of the lower eyelid improves infraorbital rhytides and widens the eye.

Botulinum-A exotoxin (BTX-A) can be used cosmetically to improve rhytides, particularly of the upper one-third of the face. In this study, fifteen women had BTX-A (BOTOX, Allergan, Inc.) injected into the orbicularis oculi muscle. One lower eyelid received two units just subdermally in the midpupillary line three millimeters below the ciliary margin. The opposite periocular area received two units BTX-A in the lower eyelid with 12 units BTX-A injected into the lateral orbital ("crow's foot") area. Three injections of four units each were placed 1.5 cm from the lateral canthus, each 1 cm apart. Patients and physicians independently evaluated the degree of improvement (grade 0 = no improvement, grade 1 = mild improvement, grade 2 = moderate improvement, and grade 3 = dramatic improvement). An independent photographic analysis was performed. Patients reported a grade of 0.73 when two units were injected alone into the lower lid, and a grade of 1.9 when the lower eyelid and the lateral orbital areas were injected. Physician assessment was grade 0.7 with injection of the eyelid alone and grade 1.8 with injection of the lower eyelid and lateral orbital area. Single investigator photographic analysis demonstrated that 40% of the subjects who had injection of the lower eyelid alone had an increased palpebral aperture (IPA), while 86% of the subjects who had injection of the lower eyelid and lateral orbital area had an IPA. Subjects receiving two units alone had an average 0.5 mm IPA and a mean 1.3 mm IPA at full smile. Concomitant treatment of the lateral orbital area produced a mean 1.8 mm IPA at rest and a mean 2.9 mm IPA at full smile. The results were more notable in the Asian eye. Two units of BTX-A injected into the lower eyelid orbicularis oculi muscle improves infraorbital wrinkles, particularly when used in combination with BTX-A treatment of the lateral orbital area.

The efficacy of powered liposuction.

BACKGROUND: Powered liposuction is a relatively new innovation for more efficient removal of adipose tissue. OBJECTIVE: To evaluate the effectiveness of powered liposuction in removing adipose tissue when compared to traditional liposuction. METHODS: Four powered liposuction devices were evaluated in the power on mode vs. the power off. The fat extracted in each of these modes was measured in a mucous specimen trap. RESULTS: There was increased fat extraction in the powered mode for all instruments. The increased rate of fat extraction varied from 20 to 45% between instruments. the overall increased extraction in powered vs. nonpowered mode was 30%. CONCLUSION: The powered liposuction devices tested significantly increase the efficacy of subcutaneous fat removal during liposuction.

The outcome in the United States after thoracoabdominal aortic aneurysm repair, renal artery bypass, and mesenteric revascularization.

OBJECTIVES: The purpose of this study was to determine outcome and identify predictors of death after thoracoabdominal aortic aneurysm (TAA) repair, renal artery bypass (RAB), and revascularization for chronic mesenteric ischemia (CMI). PATIENTS AND METHODS: In this retrospective analysis, data were obtained from the Nationwide Inpatient Sample, a 20% all-payer stratified sample of hospitals in the United States during 1993 to 1997. Patients were identified by the presence of a diagnostic or procedure code from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The main outcomes we examined were death, ICD-9-CM -based complications, length of stay, hospital charges, and disposition. A multivariate model was constructed to predict death. RESULTS: A total of 2934 patients were identified (TAA, 540; RAB, 2058; CMI, 336) in the database. The mean age was comparable (TAA, 69 +/- 9 years; RAB, 66 +/- 12 years; CMI, 66 +/- 11 years), but the breakdown between the sexes varied by procedure (male: TAA, 53%; RAB, 55%; CMI, 24%). The mortality rate (TAA, 20.3%; RAB, 7.1%; CMI, 14.7%), complication rate (TAA, 62.2%; RAB, 37.4%; CMI, 44.6%), and the percentage of patients discharged to another institution (TAA, 21.2%; RAB, 9.3%; CMI, 12.0%) were clinically significant for all procedures. The mortality rate for RAB was greater when performed concomitant with an aortic reconstruction (4.4% vs 8.3%). All three procedures were resource intensive as reflected by the median length of stay (TAA, 14 days; RAB, 9 days; CMI, 14 days) and median hospital charges (TAA, $64,493; RAB, $36,830; CMI, $47,390). The multivariate model identified several variables for each procedure that had an impact on the predicted mortality rate (TAA, 14%-76%; RAB, < 1%-46%; CMI, < 2%-87%). CONCLUSIONS: The operative mortality rates across the United States for patients undergoing TAA repair and RAB are greater than commonly reported in the literature and mandate reexamining the treatment strategies for these complex vascular problems.

Experience in the United States with intact abdominal aortic aneurysm repair.

OBJECTIVES: The purpose of this study was to determine the current outcome in the United States and to identify predictors of mortality and "bad outcome" after open, intact abdominal aortic aneurysm (AAA) repair. METHODS: In a retrospective analysis, data were obtained from the Nationwide Inpatient Sample during 1994-1996. The Nationwide Inpatient Sample is a 20% all-payer stratified sample of nonfederal United States hospitals. Patients older than 49 years were identified by the presence of primary diagnostic (441.4-intact AAA) and procedure (38.44-resection of abdominal aorta with replacement) codes of the International Classification of Diseases, Ninth Revision (ICD-9 ). In-hospital mortality rate, discharge disposition, bad outcome (death or discharge to an institution), complications (ICD-9 postoperative codes), length of stay, and charges were determined. The mortality rate and bad outcome were analyzed by the use of patient demographics (age, sex, race), patient comorbidities (ICD-9 diagnostic codes), calendar year, and hospital characteristics (size, location, teaching status) with univariate and multivariate analyses. RESULTS: We identified 16,450 intact AAAs repairs during the study years. The mean patient age was 72 +/- 7 (+/- SD) years, and most patients were male (79.7%) and white (94.6%). Most repairs were performed at large (67.3%), urban (92.5%), and nonteaching (66.7%) institutions. The in-hospital mortality rate was 4.2%, the overall complication rate was 32.4%, and 91.2% of patients were discharged home, whereas the bad outcome rate was 12.6%. The median length of stay was 8 days (mean, 10.0 +/- 8.1), and median hospital charges were $28,052 (mean, $35,681 +/- $33,006) in 1996 dollars. Multivariate analysis showed that the mortality rate (P <.05) increased with age (70-79 years, 1.8 odds ratio [OR] [95% CI, 1.4-2.3], > 79 years, 3.8 OR [95% CI, 2.9-4.9]), sex (female, 1.6 OR [95% CI, 1.3-1.9]), cerebral vascular occlusive disease (1.8 OR [95% CI, 1.3-2.5]), preoperative renal insufficiency (9.5 OR [95% CI, 7.7-11.7]), and more than three comorbidities (11.2 OR [95% CI, 3.6-35.4]). Multivariate analysis also showed that bad outcome was associated with the same variables in addition to hospital size (small/medium), year of procedure (1996), chronic obstructive pulmonary disease, and two to three comorbidities. CONCLUSIONS: Outcome after open repair of intact AAA across the United States is quite good. Older, sicker patients may benefit from nonoperative treatment or the potentially lower risk endovascular approaches.

When one liter does not equal 1000 milliliters: implications for the tumescent technique.

BACKGROUND: Tumescent anesthesia has revolutionized the practice of liposuction. Inherent to the tumescent technique is the use of large volumes of dilute solutions of lidocaine with epinephrine instilled into subcutaneous fat deposits. Precise formulation of the tumescent anesthesia is essential to liposuction technique. OBJECTIVES: To determine the actual volumes of fluids contained in intravenous (IV) 1 L bags of saline used for tumescent anesthesia, to calculate volumes supplied in 50 cc stock solutions of 1% lidocaine, and to measure the amount of fluid retained by peristalic pump tubing used for infiltration. METHODS: The amount of saline contained in fifteen 1 L saline bags from three different manufacturers was calculated using graduated cylinder methodology. The volume of tumescent anesthesia retained by peristaltic pump tubing was calculated by expelling the contents of the filler tubing and measuring it. The actual amount of 1% lidocaine contained within fifteen 50 ml "stock" 1% lidocaine bottles from different manufacturers and with different lot numbers was calculated by transferring the contents into graduated cylinders. RESULTS: One liter IV bags of physiologic saline contained an average volume of 1051 ml (range 1033-1069 ml). The 50 ml bottles of 1% lidocaine with epinephrine contain an average of 54 ml of anesthetic (range 52.5-55 ml). Infusion tubing for use with peristaltic pumps may retain 46-146 ml of tumescent anesthesia. CONCLUSION: One liter IV bags of normal saline contain more than 1 L, having an average volume of 1051 ml. Common methods of preparation of 0.05% lidocaine with 1:1,000,000 epinephrine and sodium bicarbonate can increase the total amount of fluid in the tumescent anesthesia to 1112 ml for 0.05% solutions and preparation of a 0.1% solution contains an average volume of 1162 ml. The fluid contained in each bag may be increased over labeling by as much as 11-16%. Final concentrations of lidocaine in tumescent anesthesia may be reduced due to extra fluids. A 0.05% lidocaine solution may have a final lidocaine concentration of 0.045% and a 0.1% lidocaine solution may have an actual concentration of 0.086%. Lidocaine concentrations may be reduced by as much as 10-14%. Extra anesthesia fluid is also contained within stock 50 ml bottles of 1% lidocaine. Dermatologic surgeons should be aware of extra fluid possibly contained within tumescent anesthetic preparation, be aware of the extra anesthesia supplied in standard 1% lidocaine bottles, and possible decreased concentration of lidocaine within the final tumescent anesthesia.

Long-term outcome after treatment of aortic graft infection with staged extra-anatomic bypass grafting and aortic graft removal.

OBJECTIVE: The purpose of this study was to determine long-term outcome in patients with infected prosthetic aortic grafts who were treated with extra-anatomic bypass grafting and aortic graft removal. METHODS: Between January 1989 and July 1999, 36 patients were treated for aortic graft infection with extra-anatomic bypass grafting and aortic graft removal. Extra-anatomic bypass graft types were axillofemoral femoral (5), axillofemoral (26; bilateral in 20), axillopopliteal (3; bilateral in 1) and axillofemoral/axillopopliteal (2). The mean follow-up was 32.3 +/- 4. 8 months. RESULTS: Four patients (11%) died in the postoperative period, and two patients died during follow-up as a direct consequence of extra-anatomic bypass grafting and aortic graft removal (one died 7 months after extra-anatomic bypass graft failure, one died 36 months after aortic stump disruption). One additional patient died 72 months after failure of a subsequent aortic reconstruction, so that the overall treatment-related mortality was 19%, whereas overall survival by means of life table analysis was 56% at 5 years. No amputations were required in the postoperative period, but four patients (11%) required amputation during follow-up. Twelve patients (35%) had extra-anatomic bypass graft failure during follow-up, and six patients underwent secondary aortic reconstruction (thoracobifemoral [2], iliofemoral [2], femorofemoral [2]). However, with the exclusion of patients undergoing axillopopliteal grafts (primary patency 0% at 7 months), only seven patients (25%) had extra-anatomic bypass graft failure, and only two patients required amputation (one after extra-anatomic bypass graft removal for infection, one after failure of a secondary aortic reconstruction). Furthermore, primary and secondary patency rates by means of life table analysis were 75% and 100% at 41 months for axillofemoral femoral grafts and 64% and 100% at 60 months for axillofemoral grafts. Only one patient required extra-anatomic bypass graft removal for recurrent infection, and only one late aortic stump disruption occurred. CONCLUSIONS: Staged extra-anatomic bypass grafting (with axillofemoral bypass graft) and aortic graft removal for treatment of aortic graft infection are associated with acceptable early and long-term outcomes and should remain a primary approach in selected patients with this grave problem.

Financial impact of tertiary care in an academic medical center.

OBJECTIVE: To analyze the financial impact of three complex vascular surgical procedures to both an academic hospital and a department of surgery and to examine the potential impact of decreased reimbursements. SUMMARY BACKGROUND DATA: The cost of providing tertiary care has been implicated as one potential cause of the financial difficulties affecting academic medical centers. METHODS: Patients undergoing revascularization for chronic mesenteric ischemia, elective thoracoabdominal aortic aneurysm repair, and treatment of infected aortic grafts at the University of Florida were compared with those undergoing elective infrarenal aortic reconstruction and carotid endarterectomy. Hospital costs and profit summaries were obtained from the Clinical Resource Management Office. Departmental costs and profit summary were estimated based on the procedural relative value units (RVUs), the average clinical cost per RVU ($33.12), surgeon charges, and the collection rate for the vascular surgery division (30.2%) obtained from the Faculty Group Practice. Surgeon work effort was analyzed using the procedural work RVUs and the estimated total care time. The analyses were performed for all payors and the subset of Medicare patients, and the potential impact of a 15% reduction in hospital and physician reimbursement was analyzed. RESULTS: Net hospital income was positive for all but one of the tertiary care procedures, but net losses were sustained by the hospital for the mesenteric ischemia and infected aortic graft groups among the Medicare patients. In contrast, the estimated reimbursement to the department of surgery for all payors was insufficient to offset the clinical cost of providing the RVUs for all procedures, and the estimated losses were greater for the Medicare patients alone. The surgeon work effort was dramatically higher for the tertiary care procedures, whereas the reimbursement per work effort was lower. A 15% reduction in reimbursement would result in an estimated net loss to the hospital for each of the tertiary care procedures and would exacerbate the estimated losses to the department. CONCLUSIONS: Caring for complex surgical problems is currently profitable to an academic hospital but is associated with marginal losses for a department of surgery. Economic forces resulting from further decreases in hospital and physician reimbursement may limit access to academic medical centers and surgeons for patients with complex surgical problems and may compromise the overall academic mission.

Use of superficial femoral vein for hemodialysis arteriovenous access.

Maintaining hemodialysis access in the expanding number of patients with end-stage renal disease is a difficult and challenging problem. Published guidelines outline the initial recommendations for hemodialysis access; however, there is little consensus about the most appropriate options for the subset of patients with repeated access failures and/or unsuitable veins. Two case reports are presented describing the use of composite saphenous-superficial femoral vein autogenous accesses placed in the upper and lower extremities. The function of the autogenous accesses appeared to be similar to a mature arteriovenous fistula in the short-term, although further longitudinal studies are required. The superficial femoral vein may be a useful hemodialysis access conduit for patients with limited access options.

Topical revitalization of body skin.

Topical treatments for the body are beneficial for photoageing as well as for specific disease processes, such as scars or striae. Every patient should topically apply photoprotectants in order to prevent photodamage to the skin. Tretinoin can improve body skin and has a documented use in striae. Alpha-hydroxy acids can restore body skin when used on a regular basis. Antioxidants may be of benefit. Scars can be improved with a variety of topically applied agents ranging from silicone gel sheeting to super-potent topical steroids. Chemical peeling for the body can improve the skin with the use of alpha- or beta-hydroxy acids. While topical therapy can improve body skin, adjunctive surgical therapy may be needed to correct body skin disorders or concerns fully.

The "facelift" flap for reconstruction of cheek, lateral orbit, and temple defects.

BACKGROUND: Large defects of the cheek, lateral orbit, zygomatic arch, or the lower temple pose challenges for reconstruction. These defects can be elegantly reconstructed using the "facelift" flap. OBJECTIVE: The facelift flap is a large advancement flap with a rotational component based on rhytidectomy principles. METHODS: Redundant skin from the lower cheek is used as the donor tissue, which is advanced cephalad and posteriorly. Flap design varies slightly for men and women depending on characteristics of the external ear and ear lobe as well as the position and density of the preauricular hairline. Extensive undermining is critical to reduce tension on the flap and allow for complete closure. Traction provided by an assistant aids in the undermining. Specialized instruments are helpful when performing this flap. Rhytidectomy scissors, multipronged skin rakes, hand-held fiberoptic lighted retractor, and insulated forceps are particularly useful. Correct trimming of the flap and ear lobe placement without tension on the lobe are essential for a good cosmetic result. A large standing cone is excised retroauricularly such that the scar is hidden primarily behind the ear. RESULTS AND CONCLUSION: The facelift flap gives superior and elegant results for reconstruction of large cutaneous defects involving the cheek, lateral orbit, zygomatic arch, and lower temple.

Elder care and the dermatologic surgeon.

BACKGROUND: The elderly are an increasing percentage of the population and dermatologic surgeons will be caring for more senior citizens. OBJECTIVE: Understanding issues in geriatric care will help both surgeons and patients have productive and rewarding encounters. METHODS: Approaches to the care of elders are detailed in this article. Surgical tips for the senior patient are prescribed. RESULTS: Older patients need more time and may need special assistance. Multiplicity of disease increases with age. A third-party interview can be helpful in gathering information. The elderly have sensory loss and benefit from extra attention, follow-up telephone calls, and therapeutic touch. Written handouts and instructions printed in large type are excellent. Dermatologic care should be kept as simple as possible with surgical closures designed to require minimal attention. Be cognizant of the social services available for the elderly and watch for dermatologic signs of internal disease. A skin care program for the elderly is helpful and cosmetic procedures are of interest to seniors. CONCLUSIONS: Dermatologic surgeons can provide excellent care to elders. An understanding of gerontologic issues and surgical tips can help the dermatologic surgeon care for the older patient.

Surgical decision making for carotid endarterectomy and contemporary magnetic resonance angiography.

BACKGROUND: Benefit from carotid endarterectomy (CEA) centers on patient selection and percent stenosis as determined by cerebral angiography. However, angiography remains expensive and poses risks. Validated carotid duplex ultrasonography has proven to be an accurate tool for selecting patients for CEA. However, the role of another noninvasive test-magnetic resonance angiography (MRA)-remains uncertain. Because of recent advances in MRA hardware and software, we hypothesized that clinically appropriate patients could be accurately selected for CEA based on MRA alone. METHODS: Fifty-four carotid arteries in 29 patients (with and without symptoms) underwent both three-dimensional time-of-flight MRA (1.5 Tesla) with multiple overlapping thin slab acquisition and biplanar intra-arterial digital subtraction angiography. All patients undergoing both tests over a 24-month period were included. The majority of these patients did not undergo carotid duplex ultrasound owing to the clinical practice of the hospital's neurosurgery service. Staff radiologists interpreted each study. The accuracy of patient selection based on MRA was calculated using angiography as the standard (NASCET method). Since operative thresholds vary depending on clinical history, we considered four commonly used ranges of percent stenosis for CEA. RESULTS: Patient selection accuracy of MRA alone was low, but increased as percent stenosis increased. Out of 10 occluded arteries by angiography, 5 were interpreted as patent with stenosis (70% to 99%) by MRA. One patent artery was misread as occluded on MRA. CONCLUSION: Reliance solely on contemporary MRA for surgical decision making cannot be justified in view of low accuracy, which leads to high rates of error in patient selection for CEA.

Preoperative evaluation of the liposuction patient.

Tumescent liposuction is a safe and effective procedure. It is best used in normal individuals with localized areas of adiposity and good overlying skin tone. Patients must have realistic goals and expectations. Meticulous surgical technique is essential, and care must be taken to remove the correct amount of fat in the appropriate plane. Careful patient selection following a preoperative assessment will result in a very satisfying procedure for both the patient and physician.