Surgical Site Infections

Primitive ancestors of Homo sapiens and their colonizing bacteria have coevolved for approximately 500,000 years; some experts estimate that the total number of human cells is 1013 and the total number of colonizing microbes is 1014. Despite this 10-to-1 inequity, the balance of power is influenced by an intact human immune system and the integrity of the skin and mucous membranes. Operative procedures disrupt this balance, resulting in a risk of surgical-site infections from endogenous flora, including colonizing strains of Staphylococcus aureus.

The Centers for Disease Control and Prevention (CDC) term for infections associated with surgical procedures was changed from surgical wound infection to surgical site infection in 1992 . These infections are classified into incisional, organ, or other organs and spaces manipulated during an operation; incisional infections are further divided into superficial (skin and subcutaneous tissue) and deep (deep soft tissue-muscle and fascia). These definitions should be followed universally for surveillance, prevention, and control of surgical site infections.

Surgical site infections (SSIs) initiated during invasive procedures can require additional and/or extended treatment. Despite the best efforts of healthcare facilities to maintain safe surgical environments, surgical site infections result in up to $10 billion in treatment costs every year in the U.S. alone.
* 780,000 out of 30 million surgical procedures performed annually in the U.S. result in SSI.1
* In the United Kingdom, the estimated direct costs for a patient who has developed a surgical site infection are between €2,265 and €2,518.2
* According to a study in the Netherlands, SSIs result in 5.8 to 17 extra days of hospitalization.3
* In France, approximately 11% of surgical patients acquire a surgical site infection.4

Some common causes of SSI are:
* Complications from surgical hypothermia
* Contamination of the incision area by skin flora
* Bacterial cross–contamination
* Surgical instrument contamination

The pathogens isolated from infections differ, primarily depending on the type of surgical procedure. In clean surgical procedures, in which the gastrointestinal, gynecologic, and respiratory tracts have not been entered, Staphylococcus aureus from the exogenous environment or the patient's skin flora is the usual cause of infection. In other categories of surgical procedures, including clean-contaminated, contaminated, and dirty, the polymicrobial aerobic and anaerobic flora closely resembling the normal endogenous microflora of the surgically resected organ are the most frequently isolated pathogens

The most critical factors in the prevention of postoperative infections, although difficult to quantify, are the sound judgment and proper technique of the surgeon and surgical team, as well as the general health and disease state of the patient. Other factors influence the development of postoperative wound infection, especially in clean surgical procedures, for which the infection rate (<3%) is generally low. Infections in these patients may be due solely to airborne exogenous microorganisms

Article taken from:
http://www.cdc.gov/ncidod/eid/vol7no2/nichols.htm
http://www.nejm.org/doi/full/10.1056/NEJMe0908753
http://www.haiwatch.com/SSI.aspx?Region=UK

BOTOX® Injections

The cosmetic form of botulinum toxin, often referred to by its product name BOTOX®, is a popular non-surgical injection that temporarily reduces or eliminates frown lines, forehead creases, crows feet near the eyes and thick bands in the neck. The toxin blocks the nerve impulses, temporarily paralyzing the muscles that cause wrinkles while giving the skin a smoother, more refreshed appearance. Studies have also suggested that BOTOX is effective in relieving migraine headaches, excessive sweating and muscle spasms in the neck and eyes.

BOTOX® is a therapeutic muscle-relaxing agent that works at motor nerve endings (nerves that lead to muscles). It is in a class of drugs called neurotoxins. BOTOX® has been granted FDA approval for use on "crow's feet," between brows, forehead, and upper lip area.

Botulinum toxin injection therapy is also used to treat dystonia—a neuromuscular disorder that produces involuntary muscle contractions, or spasm—that affects muscles that control movement in the eyes, neck, face, limbs, voice box, or the smooth muscle in the bladder. The goal of the therapy is to reduce muscle spasm and pain.

What is Botox?
BOTOX® is the commercial tradename for Botulinum Toxin Type A. Botulinum Toxin is derived from the bacterium Clostridium Botulinum.There are seven known types of C. botulinum toxin, but only types A; (BOTOX® Cosmetic) and B (Myobloc®) are used as medical treatments. When injected into muscles, Botulinum Toxin has a local effect. It blocks transmission between the nerve endings and muscle fibres around the injection site to cause weakness of the nearby muscle.

What is Botox used for?
Botox is a non-surgical cosmetic treatment for moderate to severe frown lines. It is typically used in people aged 18 to 65. Botox works by blocking nerve transmission to temporarily reduce the contractions of the facial muscles that cause frown lines.

It has been proven to be a safe and effective treatment for wrinkles, and botox injections are becoming increasingly popular.

Botulinum toxin has proven to be useful in the treatment of many forms of dystonia, including the following:
* blepharospasm–forceful involuntary closure of the eyelids
* strabismus–misalignment of the eyes
* hemifacial spasm–sudden contraction of the muscles on one side of the face
* spasmodic torticollis, or cervical dystonia–muscle spasm in the neck that causes the head to turn to one side, and sometimes forward or backward
* oromandibular dystonia–continuous spasms of the face, jaw, neck, tongue, larynx, and in severe cases, the respiratory system
* urinary retention–severe inability to urinate that requires catheterization
* spasmodic dysphonia–spasm of the vocal cords that causes sudden disruption of speech
* stuttering–repetitions of parts of words and whole words, long pauses, elongated sounds
* voice tremor–quavering vocalization
* limb spasticity (e.g., following stroke)

Is Botox safe?
BOTOX Cosmetic™ is very safe. It has been used since the 1970’s for the treatment of lazy eye muscles. Since the 2000 it has been used on millions of people yearly and in fact is the number one cosmetic procedure performed in the United States. Its side effects are local and may include:
* Slight bruising
* Short-term headache
* Tenderness at the injection site
* Temporary ptosis or drooping of the eyelid or the brows

Who can have Botox treatment?
Your doctor will decide if you can have cosmetic treatment with botox. Before starting treatment, tell your doctor if you have any disorders that affect your nerves and muscles, if you are breastfeeding, or if you are planning to become pregnant soon.

The Botox injection procedure
Your doctor will administer several tiny injections of botox directly into the muscles of your face. Prior to injection, your doctor will determine where to administer the injections by examining your ability to move certain muscles in your brow area. The entire botox injection procedure takes approximately 10 minutes and does not require anaesthesia. Discomfort is usually minimal and brief.

Doctors should avoid injection near the levator palpebrae superioris, particularly in patients with larger brow-depressor complexes. Medial corrugator injections should be placed at least 1 cm above the bony supraorbital ridge.

After the injection
You should notice an improvement in your frown lines within 3 to 7 days, the effects of which can last up to 4 months. However, results may vary. After a period of time, your frown lines will begin to reappear as the effects of botox wear off.

How often can Botox injections be given?
You can receive botox injections every 4 months. With repeated treatments, thinning of the muscles occurs, which produces longer lasting results.

How much does Botox treatment cost?
Each treatment costs around £200.

Possible side-effects of Botox
- headache
- flu-like symptoms
- temporary eyelid droop (ptosis)
- nausea
- squint/double vision
- twitching of the eye
- facial pain
- redness at the injection site
- muscle weakness

Cautions/contra-indications
Do not have botox treatment if you:
- have an infection where botox will be injected
- are allergic to any of the ingredients
- are pregnant or think you might be pregnant
- have a neurological disorder (eg. Myasthenia Gravis)

There are also a number of medicines that may interact with botox (eg. quinidine, some antibiotics). It is important to tell your doctor if you are taking any medication.

Source:
http://www.neurologychannel.com/botulinum/index.shtml
http://www.medic8.com/healthguide/articles/botox.html
http://www.plasticsurgery.org/Patients_and_Consumers/Procedures/Cosmetic_Procedures/Botox.html
http://www.beautifulself.com/botox.htm
http://science.nationalgeographic.com/science/enlarge/botox-injection.html
http://icondenver.com/botox.html
http://www.acclaimimages.com/_gallery/_pages/0072-0603-1620-4054.html
http://img.dailymail.co.uk/i/pix/2007/11_03/beforeAfterGPX2011_468x459.jpg
http://www.fda.gov/fdac/graphics/2002graphics/botoxZ.jpg

Liposuction, Beauty & Risk

Globally, the World Health Organization estimated that in 2005, 400 million people were obese. Currently, 78 million Americans are classified as obese. This number is projected to increase to 700 million world-wide by the year 2015.

Liposuction is defined as the removal of fat from deposits beneath the skin using a hollow stainless steel tube (called a cannula) with the assistance of a powerful vacuum. Liposuction can be accomplished either with the use of general anesthesia, or with heavy IV sedation, or totally by local anesthesia.

1. Tumescent Technique – A saline solution is injected through slit incision in the skin, and then allowed to diffuse (percolate) through the fatty tissue. Best for in-office surgery, since agents in the solution reduce bleeding. This technique is the safest and it allows for a faster recovery, but it’s also the most expensive. Percolating can take up to 60 minutes, which means an extra hour of operating-room costs.

2. Ultrasound-assisted Lipoplasty (UAL): An ultrasonic vibrating probe “liquefies” the fat before it is suctioned. It can be done externally, through a hand-held device applied to the skin, or internally, through a vibrating canule. UAL is the preferred method in clinics.

Modified Tumescent Liposuction
Modified tumescent liposuction refers to a combination of tumescent local anesthesia plus some form of systemic anesthesia (general anesthesia or heavy IV sedation), they must be administered by an anesthesiologist.

The Different Liposuction Techniques
There are many ways to do liposuction, for example liposuction can be accomplished painlessly either totally by local anesthesia or with general anesthesia. In the realm of liposuction, maximum speed and maximum volume of aspirate are not criteria for excellence. Ultimately, excellence is measured in terms of patient happiness which is a function of safety, patient comfort, finesse, and quality of results.

Liposuction Complications
Liposuction complications are often the direct result of lack of caution, poor judgment, over confidence, ignorance about pharmacology, or adherence to faulty dogma.

The "Art of Liposuction"
Liposuction is a medium of artistic expression that displays itself in (1) a practical application of scientific knowledge, (2) the production of what is beautiful, (3) a perfection of workmanship, (4) a perpetual quest for improvement in technique, and (5) a skill attained through clinical experience, and above all (6) making people feel happy about what they see in the mirror.

Artistry and Safety are Related
In order to master an artistic liposuction technique, the surgeon must have the skill and intelligence to avoid exposing patients to unnecessary dangers. The true artist provides better results, and uses the safest technique and never forgets the duty to "first, do no harm." . It is not artistry to take unnecessary risks or push liposuction to the limits of safety.

Risks of Liposuction
As with any surgery, liposuction carries some risks. These include:

• Infection
• The formation of fat clots or blood clots, which can loosen and move to the lungs (a potentially fatal condition called pulmonary embolism)
• Too much fluid loss, leading to shock and potentially death
• Fluid accumulation
• Nerve damage that causes numbness or changes in sensation
• Swelling that lasts for several weeks or months after the procedure
• Skin death (necrosis), in which the skin above the liposuction site sloughs off and dies and/or becomes infected
• Burns from the ultrasound probe
• Punctures to the organs (For example, the intestines may be punctured during abdominal liposuction.)
• Drug reactions, including reactions to the lidocaine fluid that is injected in the tumescent and super-wet techniques
• Rippling or indentation under the skin if the doctor removes too much fat
• Scarring (although doctors make every attempt to keep the scars small and hidden)

Tumescent Technique is Safest
The tumescent technique for liposuction is unquestionably the safest form of liposuction. When tumescent liposuction is done correctly (not excessively), it is a very safe procedure, there have been no reported deaths associated with tumescent liposuction totally by local anesthesia. The dilute epinephrine contained in the tumescent anesthetic solution profoundly shrinks capillaries and thus virtually eliminates surgical blood loss.

Smoother Cosmetic Results
The tumescent technique permits the use of microcannulas which in turn yields smoother cosmetic results. Traditional liposuction cannulas (stainless steel tubes) have a relatively large diameter and remove fat rather quickly. However, with the use of large cannulas (diameter greater than 3 millimeters) there is an increased risk of irregularities and depressions in the skin. Microcannulas with a diameter less than 3 millimeters, allow fat to be removed in a smoother and more uniform fashion. Some surgeons prefer larger cannulas because it allows liposuction to be done more quickly.

Rapid Healing
After tumescent liposuction, there is a certain amount of blood-tinged local anesthetic solution that remains under the skin. This excess fluid is either slowly absorbed over several weeks into the blood stream, or it can be rapidly removed by drainage through skin incisions and absorbed by special absorptive pads (HK Pads).

Source:
How Liposuction Works. Stephanie Watson. http://static.howstuffworks.com
Liposuction. http://www.peacemotivate.com/2007/09/09/liposuction/
IAPAM's 7 Top Anti-Aging Trends for 2009. Jeff Russell. http://www.prweb.com/releases/antiaging/trends/prweb1907894.htm
Liposuction Information. http://www.liposuction.com/lipoinfo/intro.php
Liposuction Facts. http://www.cosmeticsurgery.com/essential_facts/cosmetic-surgery
Liposuction: Facts and Myths . Diana Bocco. http://www.googobits.com/articles/1045-liposuction-facts-and-myths.html/Liposuction/