Aesthetic/Cosmetic Surgery and Ethical Challenges.

Is aesthetic surgery a business guided by market structures aimed primarily at material gain and profit or a surgical intervention intended to benefit patients and an integral part of the health-care system? Is it a frivolous subspecialty or does it provide a real and much needed service to a wide range of patients? At present, cosmetic surgery is passing through an identity crisis as well as an acute ethical dilemma. A closer look from an ethical viewpoint makes clear that the doctor who offers aesthetic interventions faces many serious ethical problems which have to do with the identity of the surgeon as a healer. Aesthetic surgery that works only according to market categories runs the risk of losing the view for the real need of patients and will be nothing else than a part of a beauty industry which has the only aim to sell something, not to help people. Such an aesthetic surgery is losing sight of real values and makes profit from the ideology of a society that serves only vanity, youthfulness, and personal success. Unfortunately, some colleagues brag that they chose the plastic surgery specialty just to become rich aesthetic surgeons, using marketing tactics to promote their practice. This is, at present, the image we project. As rightly proposed, going back a little to Hippocrates, to the basics of being a physician, is urgently warranted! Being a physician is all that a ''cosmetic'' surgeon should be. In the long run, how one skillfully and ethically practices the art of plastic surgery will always speak louder than any words.

Infantile fibrosarcoma misdiagnosed as vascular tumors.

Clinical as well as radiologic diagnosis of infantile fibrosarcoma (IFS) is often a challenging problem due to similarities with tumors of vascular origin. Consequently, in the majority of cases, histological and immunohistochemical studies are considered gold standards for the final diagnosis. The two case reports and the review of literature discussed should increase the important features in the history and the presentation that increase the index of suspicion for IFS, as well as it highlights the important characteristics of imaging and laboratory studies that confirm its diagnosis.

Reverse tissue expansion by liposuction deflation for revision of post-surgical thigh scars.

Scars hypertrophy and widen when stretching mechanical forces are applied to resilient newly formed collagen before it reaches final maturity marring the final result of many surgical procedures and resulting in a clinical problem for many patients. Scar revision by surgical excision remains the traditional treatment for hypertrophic or widespread scars. It relies upon recruitment of local tissues for closure of the ensuing defect. Providing tension-free skin closure is the best option to avoid recurrence. Although tissue expansion procedure is a valuable and reliable technique for scar revision, it has its own disadvantages and potential complications. We describe an alternative method for scar revision that may be applicable in certain situations. Instead of expanding the soft tissues to make available additional skin, deflation by liposuction may be affected to relax the skin envelope thus indirectly providing additional skin for scar revision. We call this method 'reverse tissue expansion'.

Management of war-related burn injuries: lessons learned from recent ongoing conflicts providing exceptional care in unusual places.

Thermal injury is a sad but common and obligatory component of armed conflicts. Although the frequency of noncombat burns has decreased, overall incidence of burns in current military operations has nearly doubled during the past few years. Burn injuries in the military environment do not need to be hostile in nature. Burns resulting from carelessness outnumber those resulting from hostile action. Unfortunately, civilians are becoming the major targets in modern-day conflicts; they account for more than 80% of those killed and wounded in present-day conflicts. The provision of military burn care mirrors the civilian standards; however, several aspects of treatment of war-related burn injuries are peculiar to the war situation itself and to the specific conditions of each armed conflict. Important aspects of management of burned military personnel include triage to ensure that available medical care resources are matched to the severity of burn injury and the number of burn casualties, initial management and resuscitation in the combat zone, and subsequent evacuation to higher echelons of medical care, each with increasing medical capabilities. Care of military victims is usually well structured and follows strict guidelines for first aid and evacuation to field hospitals by military personnel usually having had some form of training in first aid and resuscitation and for which necessary equipment and material for such interventions are more or less available. Options available for civilian injury intervention in wartime, however, are limited. Of all pre-hospital transport of civilian victims, 70% are done by lay public and 93% receive in the field, or during transport, some form of basic first aid administered by relatives, friends, or other first responders not trained for such interventions. Civilian casualties frequently represents 60% to 80% of all injured admitted to the level III facilities of overseas forces stationed throughout the host country. Unlike military personnel who are rapidly evacuated to higher echelons IV and V for definitive and long-term care, civilians must receive definitive burn treatment at these level III military facilities. The present review was intended to highlight peculiar aspects of war-related burn injuries of both military personnel and civilians and their management based on the most recently published material that, for the most part, is related to the recent conflicts in Iraq and Afghanistan.

Provision of essential surgery in remote and rural areas of developed as well as low and middle income countries.

BACKGROUND: Surgery is increasingly becoming an integral part of public health and health systems development worldwide. Such surgical care should be provided at the same type and level in both urban and rural settings. However, provision of essential surgery in remote and rural areas of developed as well as low and middle income countries remains totally inadequate and poses great challenges. METHODS: Though not intended to be a systematic review, several aspects of primary health care and its surgical aspects in remote and rural areas were reviewed. Search tools included Medline, PubMed and Scopius. Health concerns such as quality health care and limitations, as well as infrastructures, surgical workforce as well as implications for planning, teaching and training for surgical care in remote areas were searched. RESULTS: The dire shortage of surgeons and anesthesiologists in most low and middle income countries means task shifting and training of non-physician clinicians (NPCs) is the only option particularly in most developing poor countries. CONCLUSION: The best means of bringing surgical care to rural dwellers is yet to be clearly determined. However, modern surgical techniques integrated with the strategy as outlined by the World Health Organization can be brought to rural areas through specially organized camps. Sophisticated surgery can thus be performed in a high-volume and cost-effective manner, even in temporary settings. However, provision of essential surgery to rural and remote areas can only partly be met both in developed and in low and middle income countries and it will take years to solve the problem of unmet surgical needs in these areas.

Barbed sutures "lunch time" lifting: evidence-based efficacy.

There is a growing trend nowadays for patients to seek the least invasive treatments possible with less risk of complications and downtime to correct rhytides and ptosis characteristic of aging. Nonsurgical face and neck rejuvenation has been attempted with various types of interventions. Suture suspension of the face, although not a new idea, has gained prominence with the advent of the so called "lunch-time" face-lift. Although some have embraced this technique, many more express doubts about its safety and efficacy limiting its widespread adoption. The present review aims to evaluate several clinical parameters pertaining to thread suspensions such as longevity of results of various types of polypropylene barbed sutures, their clinical efficacy and safety, and the risk of serious adverse events associated with such sutures. Early results of barbed suture suspension remain inconclusive. Adverse events do occur though mostly minor, self-limited, and of short duration. Less clear are the data on the extent of the peak correction and the longevity of effect, and the long-term effects of the sutures themselves. The popularity of barbed suture lifting has waned for the time being. Certainly, it should not be presented as an alternative to a face-lift.

Mammary myocutaneous-glandular flap for reconstruction of oncological defects of the anterior midline chest wall.

We describe a mammary myocutaneous-glandular flap, which is a simple, convenient, reliable, and speedy reconstructive technique applicable for women that combines little or no morbidity with excellent cosmetic outcome and provides a simple solution to an extremely difficult problem.

The efficacy of hair and urine toxicology screening on the detection of child abuse by burning.

Abuse by burning is estimated to occur in 1 to 25% of children admitted with burn injuries annually. Hair and urine toxicology for illicit drug exposure may provide additional confirmatory evidence for abuse. To determine the impact of hair and urine toxicology on the identification of child abuse, we performed a retrospective chart review of all pediatric patients admitted to our burn unit. The medical records of 263 children aged 0 to 16 years of age who were admitted to our burn unit from January 2002 to December 2007 were reviewed. Sixty-five children had suspected abuse. Of those with suspected abuse, 33 were confirmed by the Department of Health and Human Services and comprised the study group. Each of the 33 cases was randomly matched to three pediatric (0-16 years of age) control patients (99). The average annual incidence of abuse in pediatric burn patients was 13.7+/-8.4% of total annual pediatric admissions (range, 0-25.6%). Age younger than 5 years, hot tap water cause, bilateral, and posterior location of injury were significantly associated with nonaccidental burn injury on multivariate analysis. Thirteen (39.4%) abused children had positive ancillary tests. These included four (16%) skeletal surveys positive for fractures and 10 (45%) hair samples positive for drugs of abuse (one patient had a fracture and a positive hair screen). In three (9.1%) patients who were not initially suspected of abuse but later confirmed, positive hair test for illicit drugs was the only indicator of abuse. Nonaccidental injury can be difficult to confirm. Although inconsistent injury history and burn injury pattern remain central to the diagnosis of abuse by burning, hair and urine toxicology offers a further means to facilitate confirmation of abuse.

Wound cleansing, topical antiseptics and wound healing.

Quality of care is a critical requirement for wound healing and 'good' care of wounds has been synonymous with topical prevention and management of microbial contamination. Topical antiseptics are antimicrobial agents that kill, inhibit or reduce the number of microorganisms and are thought to be essential for wounds infection control. However, they have long and commonly been used on wounds to prevent or treat infection, the merits of antiseptic fluid irrigation have received little scientific study. Unlike antibiotics that act selectively on a specific target, antiseptics have multiple targets and a broader spectrum of activity, which include bacteria, fungi, viruses, protozoa and even prions. Although certain skin and wound cleansers are designed as topical solutions with varying degrees of antimicrobial activity, concerns have been raised. Wound cleansers may affect normal human cells and may be antimitotic adversely affecting normal tissue repair. Repeated and excessive treatment of wounds with antiseptics without proper indications may have negative outcomes or promote a microenvironment similar to those found in chronic wounds. However, when applied at the proper times and concentrations, some classes of antiseptics may provide a tool for the clinician to drive the wound bed in desired directions. The present review summarises the various antiseptics in use and their negative impact on the wound healing mechanisms. It is clear that the role of antiseptics on wounds and their role in wound care management need to be reconsidered.

Burn prevention mechanisms and outcomes: pitfalls, failures and successes.

Burns are responsible for significant mortality and morbidity worldwide and are among the most devastating of all injuries, with outcomes spanning the spectrum from physical impairments and disabilities to emotional and mental consequences. Management of burns and their sequelae even in well-equipped, modern burn units of advanced affluent societies remains demanding and extremely costly. Undoubtedly, in most low and middle income countries (LMICs) with limited resources and inaccessibility to sophisticated skills and technologies, the same standard of care is obviously not possible. Unfortunately, over 90% of fatal fire-related burns occur in developing or LMICs with South-East Asia alone accounting for over half of these fire-related deaths. If burn prevention is an essential part of any integrated burn management protocol anywhere, focusing on burn prevention in LMICs rather than treatment cannot be over-emphasized where it remains the major and probably the only available way of reducing the current state of morbidity and mortality. Like other injury mechanisms, the prevention of burns requires adequate knowledge of the epidemiological characteristics and associated risk factors, it is hence important to define clearly, the social, cultural and economic factors, which contribute to burn causation. While much has been accomplished in the areas of primary and secondary prevention of fires and burns in many developed or high-income countries (HICs) such as the United States due to sustained research on the epidemiology and risk factors, the same cannot be said for many LMICs. Many health authorities, agencies, corporations and even medical personnel in LMICs consider injury prevention to have a much lower priority than disease prevention for understandable reasons. Consequently, burns prevention programmes fail to receive the government funding that they deserve. Prevention programmes need to be executed with patience, persistence, and precision, targeting high-risk groups. Depending on the population of the country, burns prevention could be a national programme. This can ensure sufficient funds are available and lead to proper coordination of district, regional, and tertiary care centres. It could also provide for compulsory reporting of all burn admissions to a central registry, and these data could be used to evaluate strategies and prevention programmes that should be directed at behavioural and environmental changes which can be easily adopted into lifestyle. Particularly in LMICs, the emphasis in burn prevention should be by advocating change from harmful cultural practices. This needs to be done with care and sensitivity. The present review is a summary of what has already been accomplished in terms of burn prevention highlighting some of the successes but above all the numerous pitfalls and failures. Recognizing these failures is the first step towards development of more effective burn prevention strategies particularly in LMICs in which burn injury remains endemic and associated with a high mortality rate. Burn prevention is not easy, but easy or not, we have no options; burns must be prevented.

Contouring of the male anterior chest following bariatric surgery and massive weight loss.

The male breast area can be difficult to treat following massive weight loss. In such patients, it is essential to correct the deformity without leaving disfiguring scars over the anterior surface of the chest, if possible. We suggest a surgical technique that involves a torsoplasty with concomitant nipple-areolar complex transposition, resulting in adequate male chest contouring with well hidden scars.

Aesthetic/Cosmetic surgery and ethical challenges.

Is aesthetic surgery a business guided by market structures aimed primarily at material gain and profit or a surgical intervention intended to benefit patients and an integral part of the health-care system? Is it a frivolous subspecialty or does it provide a real and much needed service to a wide range of patients? At present, cosmetic surgery is passing through an identity crisis as well as an acute ethical dilemma. A closer look from an ethical viewpoint makes clear that the doctor who offers aesthetic interventions faces many serious ethical problems which have to do with the identity of the surgeon as a healer. Aesthetic surgery that works only according to market categories runs the risk of losing the view for the real need of patients and will be nothing else than a part of a beauty industry which has the only aim to sell something, not to help people. Such an aesthetic surgery is losing sight of real values and makes profit from the ideology of a society that serves only vanity, youthfulness, and personal success. Unfortunately, some colleagues brag that they chose the plastic surgery specialty just to become rich aesthetic surgeons, using marketing tactics to promote their practice. This is, at present, the image we project. As rightly proposed, going back a little to Hippocrates, to the basics of being a physician, is urgently warranted! Being a physician is all that a "cosmetic" surgeon should be. In the long run, how one skillfully and ethically practices the art of plastic surgery will always speak louder than any words.

Aesthetic surgery and religion: Islamic law perspective.

BACKGROUND: Plastic surgeons are called upon to perform aesthetic surgery on patients of every gender, race, lifestyle, and religion. Currently, it may seem natural that cosmetic surgery should be perceived as permissible, and in our modern liberal age, it seems strange to attempt justifying certain surgical acts in the light of a particular cultural or religious tradition. Yet every day, cruel realities demonstrate that although the foremost intention of any scripture or tradition has been mainly to promote religious and moral values, most religions, including Christianity, Islam, and Judaism, invariably affect human behavior and attitude deeply, dictating some rigid positions regarding critical health issues. METHODS: A Web search was conducted, and the literature was reviewed using the Medline search tool. RESULTS: Islamic law closely regulates and governs the life of every Muslim. Bioethical deliberation is inseparable from the religion itself, which emphasizes continuities between body and mind, between material and spiritual realms, and between ethics and jurisprudence. CONCLUSIONS: The rule in Islam is that individuals should be satisfied with the way Allah has created them. Islam welcomes, however, the practice of plastic surgery as long as it is done for the benefit of patients. Even if it clearly considers "changing the creation of Allah" as unlawful, Islamic law is ambiguous regarding cosmetic surgery. Its objection to cosmetic surgery is not absolute. It is rather an objection to exaggeration and extremism. It has been mentioned that "Allah is beautiful and loves beauty."

Pharmacological modulation of wound healing in experimental burns.

Factors involved in wound healing and their interdependence are not yet fully understood; nevertheless, new prospects for therapy to favor speedy and optimal healing are emerging. Reports about wound healing modulation by local application of simple and natural agents abound even in the recent literature, however, most are anecdotal and lack solid scientific evidence. We describe the effect of silver sulfadiazine and moist exposed burn ointment (MEBO), a recently described burn ointment of herbal origin, on mast cells and several wound healing cytokines (bFGF, IL-1, TGF-beta, and NGF) in the rabbit experimental burn model. The results demonstrate that various inflammatory cells, growth factors and cytokines present in the wound bed may be modulated by application of local agents with drastic effects on their expression dynamics with characteristic temporal and spatial regulation and changes in the expression pattern. Such data are likely to be important for the development of novel strategies for wound healing since they shed some light on the potential formulations of temporally and combinatory optimized therapeutic regimens.

Effect of silver on burn wound infection control and healing: review of the literature.

Silver compounds have been exploited for their medicinal properties for centuries. At present, silver is reemerging as a viable treatment option for infections encountered in burns, open wounds, and chronic ulcers. The gold standard in topical burn treatment is silver sulfadiazine (Ag-SD), a useful antibacterial agent for burn wound treatment. Recent findings, however, indicate that the compound delays the wound-healing process and that silver may have serious cytotoxic activity on various host cells. The present review aims at examining all available evidence about effects, often contradictory, of silver on wound infection control and on wound healing trying to determine the practical therapeutic balance between antimicrobial activity and cellular toxicity. The ultimate goal remains the choice of a product with a superior profile of infection control over host cell cytotoxicity.

Baclofen pump pocket infection: a case report of successful salvage with muscle flap.

Programmable pump for continuous infusion of intrathecal baclofen, an agonist of the inhibitory neurotransmitter gamma-aminobutyric acid, is nowadays being widely used to control spasticity. The most common complications leading to explantation of the pumps are skin breakdown and infection at the pump implantation site which cannot be effectively treated without pump removal. We report a 37-year-old man who developed a baclofen pump pocket infection that did not respond to antibiotic therapy. Because the continuation of intrathecal baclofen administration was critical to the patient, and because the high cost of the pump precluded its prompt replacement, the pump was salvaged using the ipsilateral rectus abdominis muscle that was elevated on its inferior vascular pedicle and wrapped around the pump. Abdominal skin was then approximated, leaving a small portion of exposed muscle overlying the refill site that was covered by a split-thickness skin graft. Continuous intrathecal baclofen administration was never discontinued. Three months later, the pump's refill site could be easily identified manually for pump refill. There were no signs of recurrent infection during the 2-year follow-up period.

Refinements of vertical scar mammaplasty: circumvertical skin excision design with limited inferior pole subdermal undermining and liposculpture of the inframammary crease.

Vertical scar mammaplasty, first described by Lötsch in 1923 and Dartigues in 1924 for mastopexy, was extended later to breast reduction by Arié in 1957. It was otherwise lost to surgical history until Lassus began experimenting with it in 1964. It then was extended by Marchac and de Olarte, finally to be popularized by Lejour. Despite initial skepticism, vertical reduction mammaplasty is becoming increasingly popular in recent years because it best incorporates the two concepts of minimal scarring and a satisfactory breast shape. At the moment, vertical scar techniques seem to be more popular in Europe than in the United States. A recent survey, however, has demonstrated that even in the United States, it has surpassed the rate of inverted T-scar breast reductions. The technique, however, is not without major drawbacks, such as long vertical scars extending below the inframammary crease and excessive skin gathering and "dog-ear" at the lower end of the scar that may require long periods for resolution, causing extreme distress to patients and surgeons alike. Efforts are being made to minimize these complications and make the procedure more user-friendly either by modifying it or by replacing it with an alternative that retains the same advantages. Although conceptually opposed to the standard vertical design, the circumvertical modification probably is the most important maneuver for shortening vertical scars. Residual dog-ears often are excised, resulting in a short transverse scar (inverted T- or L-scar). The authors describe limited subdermal undermining of the skin at the inferior edge of the vertical incisions with liposculpture of the inframammary crease, avoiding scar extension altogether. Simplified circumvertical drawing that uses the familiar Wise pattern also is described.

New technologies for burn wound closure and healing--review of the literature.

Methods for handling burn wounds have changed in recent decades. Increasingly, aggressive surgical approach with early tangential excision and wound closure is being applied leading to improvement in mortality rates of burn victims. Autografts from uninjured skin remain the mainstay of treatment. Autologous skin graft, however, has limited availability and is associated with additional morbidity and scarring. Severe burn patients invariably lack sufficient adequate skin donor sites requiring alternative methods of skin replacement. The present review summarizes available replacement technologies.