Severe Hypothyroidism Manifested as Acute Mania With Psychotic Features: A Case Report and Review of the Literature.

Hypothyroidism is associated with a wide array of medical, neurological, and psychiatric symptoms. Severe hypothyroidism may present as myxedema coma, a medical emergency. In addition, patients may present with myxedema psychosis, a psychiatric emergency manifested as hyperactive encephalopathy, hallucinations, delusions, and suicidal ideation. In rare instances, patients may present with symptoms of mania with psychosis. We present the case of a 26-year-old woman with no known psychiatric history who presented with gradual onset of altered mental status, distractibility, decreased need for sleep, pressured speech, and religious and paranoid delusions. Her medical history was significant for a surgically absent thyroid gland and nonadherence to thyroid hormone. The patient was found to have a severely elevated level of thyroid-stimulating hormone, low level of triiodothyronine, and undetectable thyroxine. Thyroid ultrasound demonstrated a surgically absent thyroid gland. The patient's metabolic panel and random serum cortisol level were normal. Rapid plasma reagin was nonreactive, and toxin screening was negative. It was concluded that severe hypothyroidism was the cause of the patient's mania with psychotic features, given her thyroid hormone levels and lack of history of a psychiatric or substance use disorder. Thyroid hormone monitoring and treatment of hypothyroidism is necessary in all patients who have undergone surgical excision of the thyroid gland. All patients presenting with a first episode mania should be screened for thyroid dysfunction. The preferred treatment includes an atypical antipsychotic and thyroid replacement therapy. Rapid resolution of symptoms can occur with combined levothyroxine and liothyronine. Correction of hypothyroidism improves response to antipsychotics.

The Single Incision Minimally Invasive (SIMI) Neck Lift.

BACKGROUND: With the increased focus on the neck and chin in the era of selfies and social media, neck contouring continues to be an in-demand procedure. Full correction of the neck typically requires both submental and postauricular incisions, but the postauricular incisions can be unsightly and painful. This article introduces a viable alternative for the patient. METHODS: A case series of appropriate candidates undergoing a novel neck lift technique (the single incision minimally invasive neck lift) is described. Participants include men and women with an age range of 30-70. The surgical technique incorporates shifting of the typical submental incision used in a full neck lift to a cervicomental incision, and when accompanied by wide undermining, the postauricular incisions are avoided entirely. RESULTS: Among the 20 patients in this case study, photographs show that it is possible to achieve results commonly associated with a full neck lift but without the postauricular incisions typically associated with a full neck lift. CONCLUSIONS: The single incision minimally invasive neck lift allows the surgeon to offer an effective procedure for appropriate candidates who want to treat excess fat, a sagging platysma muscle and loose, misplaced skin in the submental region without postauricular incisions typically utilized in a traditional full neck lift.

Price Transparency in the Online Age.

Plastic surgeons are sometimes hesitant to provide their pricing information online, due to several concerns. However, if implemented right, price transparency can be used as a lead generation tool that provides consumers with the pricing information they want and gives the physician the consumer's contact information for follow-up. This study took place during the author's first year in private practice in a new city. An interactive price transparency platform (ie, cost estimator) was integrated into his website, allowing consumers to submit a "wishlist" of procedures to check pricing on these procedures of interest. However, the consumer must submit their contact information to receive the desired breakdown of costs that are tailored based on the author's medical fees. During that first year, without any advertising expenditure, the author's website received 412 wishlists from 208 unique consumers. Consumers (17.8%) that submitted a wishlist came in for a consultation and 62% of those booked a procedure. The average value of a booked procedure was over US $4000 and cumulatively, all of the leads from this one lead source in that first year generated over US $92,000 in revenue. When compared with non-price-aware patients, price-aware patients were 41% more likely to book a procedure. Price transparency led to greater efficiency and reduced consultations that ended in "sticker shock." When prudently integrated into a medical practice, price transparency can be a great lead generation source for patients that are (1) paying out of pocket for medically necessary services due to a high-deductible health plan or (2) paying for services not typically covered by insurance, such as cosmetic services.

Complications from laser-assisted liposuction performed by noncore practitioners.

Liposuction is one of the most commonly performed aesthetic surgery procedures in the United States, and most plastic surgeons perform suction-assisted, ultrasound-assisted, or power-assisted liposuction. The past decade has seen a growing interest in laser-assisted liposuction (LAL) and the proposed advantages of traditional liposuction methods. However, it is performed by a minority of plastic surgeons. In fact, many LAL providers are not trained in aesthetic practice, and many offer LAL as their only body-contouring procedure. When only one method of body contouring is available to a provider, it may lead to inappropriate patient selection with associated poor outcomes. This report discusses the use of laser liposuction in body contouring and the demographics of those performing liposuction, including LAL. Complications from laser-assisted liposuction performed by noncore practitioners are illustrated.

Breast reduction: does the tumescent technique affect reimbursement?

BACKGROUND: Breast reduction is a very common procedure within the field of plastic surgery, with many techniques. These techniques include differences in the location of the pedicles and of the scars. Another variation on the technique for breast reduction relates to preoperative infiltration of an epinephrine solution to reduce blood loss and operative time. The authors' technique for breast reduction and its effect on insurance reimbursement has not previously been discussed in a large prospective study. METHODS: The authors performed a prospective study to compare a cohort of 50 patients undergoing a traditional breast reduction without infiltration of epinephrine followed by electrocautery for resection versus 50 patients receiving tumescent infiltration of epinephrine followed by sharp resection. RESULTS: The patients who underwent the tumescent technique for breast reduction had shorter operative times and similar blood loss and pain compared with the traditional technique. The use of tumescence did not cause a significant difference in the weight of the amount resected when compared with the dry, pathologic weight. CONCLUSIONS: In the first large prospective cohort study involving this technique, the authors can demonstrate the many advantages of the tumescent technique and refute their concern that tumescence can cause inaccurate weight measurements that might interfere with insurance reimbursement based on resected weight.

Lawsuits against plastic surgeons: Does locale affect incidence of claims?

BACKGROUND: Physicians continue to practice in a very litigious environment. Some physicians try to mitigate their exposure to lawsuits by avoiding geographical locations known for their high incidence of medical malpractice claims. Not only are certain areas of the United States known to have a higher incidence of litigation, but it is also assumed that certain areas of the hospital incur a greater liability. There seems to be a medicolegal dogma suggesting a higher percentage of malpractice claims coming from patients seen in the emergency room (ER), as well as higher settlements for ER claims. OBJECTIVE: To determine if there is any validity to the dogma that a higher percentage of malpractice claims arise from the ER. METHODS: An analysis of common plastic surgery consults that result in malpractice claims was performed. The location where the basis for the lawsuit arose - the ER, office (clinic) or the operating room (OR) - was evaluated. The value of the indemnity paid and whether its value increased or decreased based on the location of the misadventure was evaluated. RESULTS: According to the data, which represented 60% of American physicians, there was a larger absolute number of malpractice claims arising from the OR, not the ER. However, the highest average indemnity was paid for cases involving amputations when the misadventure originated in the ER. CONCLUSIONS: The dogma that a greater percentage of lawsuits come from incidents arising in the ER is not supported. However, depending on the patient's injury and diagnosis, a lawsuit from the ER can be more costly than one from the OR.

Hemoperitoneum secondary to avulsed short gastric arteries after vomiting: the first documented case in North America.

This is the first documented case in North America wherein a 26-year-old man presented to the emergency room with hemoperitoneum secondary to avulsed short gastric arteries after violent emesis.

Treatment of superior mesenteric and portal vein thrombosis with direct thrombolytic infusion via an operatively placed mesenteric catheter.

Acute superior mesenteric vein (SMV) and portal vein (PV) thrombosis can be a complication of hypercoagulable, inflammatory, or infectious states. It can also occur as a complication of medical or surgical intervention. Management of mesenteric and portal vein thrombosis includes both operative and nonoperative approaches. Operative interventions include thrombectomy with thrombolysis; this is often employed for patients who present with signs of peritoneal irritation. Nonoperative approaches can be either noninvasive or invasive. Treatment with anticoagulation has been shown to be efficacious, though its rate of recanalization is not as high as with intravascular infusion of thrombolytics. Intravenous catheterization and thrombolytic infusion has the advantage of direct pharmacologic thrombolysis of clot, with decreased infusion required and the possibility to carry out dilation or thrombectomy concurrently. We report the use of recombinant tissue-plasminogen activator (rt-PA) infusion via an operatively placed multi side-hole catheter/5-Fr introducer sheath into the right portal and superior mesenteric vein clot, inserted through a small jejunal vein, in a patient who presented with acute gangrenous appendicitis and thrombosis of the main portal trunk and superior mesenteric vein. A temporary abdominal closure was maintained until 36 hours after the start of infusion of the rt-PA. At this time venous system had normal flow, with complete recanalization of the right portal and superior mesenteric veins.

Anterolateral thigh flap for breast reconstruction: review of the literature and case reports.

More women than ever before are undergoing mastectomies secondary to increased awareness and screening. This has also caused a corresponding increase in the number of breast reconstructions requested each year. The demand for improved results has fueled recent advances in new techniques. Aside from implant reconstruction, the methods now being employed are related to autogenous donations and reconstruction. Currently, the most commonly used techniques for autogenous breast reconstruction are the DIEP (deep inferior epigastric perforator) and TRAM (transverse rectus abdominis myocutaneous) flaps from the lower abdomen. The anterolateral thigh flap is a type of perforator flap usually described for use in head and neck reconstruction. The authors have discovered this flap's utility as an alternative in autogenous breast reconstruction when the abdomen is not available as a donor site. A review of the literature reveals a dearth of experience in using the anterolateral thigh flap for breast reconstruction. The article reviews the literature with regard to current uses of the anterolateral thigh flap, and then reports three case studies which highlight the thigh flap as an excellent alternative for breast reconstruction in selected patients.