Alan H. Gold

Mortality in outpatient surgery.

Background: The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) has reported statistics on morbidity and mortality for facilities that it accredits based on an analysis of unanticipated sequelae and surgical mortality. Data acquired through the first Internet-Based Quality Assurance and Peer Review reporting system (IBQAP) were reviewed and published in 2004. This article reports the accumulated data in the IBQAP through June of 2006, analyzing death associated with procedures performed in facilities approved by the AAAASF. With the exception of some statistics on the Medicare-aged population, there are few data reported in the literature related to deaths in outpatient surgery. Methods: The IBQAP, designed in 1999 by the AAAASF, mandates biannual reporting of all unanticipated sequelae and random case reviews by all surgeons operating in AAAASF–accredited facilities. Surgical log numbers, whose entry is required, allow for tabulation of the number of cases and procedures performed by individual reporting surgeons. Results: In this review of data collected using the IBQAP from January of 2001 through June of 2006, there were 23 deaths in 1,141,418 outpatient procedures performed. Pulmonary embolism caused 13 of the 23 deaths. Only one death occurred as the result of an intraoperative adverse event. Conclusions: A pulmonary embolism may occur after any operative procedure, whether it is performed in a hospital, an ambulatory surgery center, or a physician’s office-based surgery facility. The procedure most commonly associated with death from pulmonary embolism in an office-based surgery facility is abdominoplasty. The frequency of pulmonary embolism associated with abdominoplasty warrants further study to determine predisposing factors, understand its cause, and introduce guidelines to prevent its occurrence.

A prospective, multi-site investigation of patient satisfaction and psychosocial status following cosmetic surgery

BACKGROUND Although several studies have investigated patient satisfaction and changes in body image following aesthetic plastic surgery, few have investigated more specific dimensions of body image, including dysphoric emotions that occur in specific social situations or body image quality of life. In addition, few studies have investigated changes in body image that may occur in concert with changes in more general areas of psychosocial functioning, such as depressive symptoms and self-esteem. OBJECTIVE This prospective, multi-site study investigated postoperative satisfaction and changes in psychosocial status following cosmetic surgery. METHODS One hundred patients recruited from 8 geographically diverse surgical practices completed psychometric measures of body image, depressive symptoms, and self-esteem prior to surgery. Seventy-two patients completed the 3-month postoperative assessment, 67 completed the 6-month assessment, and 63 completed the 12-month assessment. All statistical tests on changes after surgery were conducted using the sample of 72 patients who completed the 3-month assessment. A Last Observation Carried Forward analysis was used to account for patients who did not complete the subsequent follow-up assessments. In addition, they reported their postoperative satisfaction as well as self-rated attractiveness at the 3 postoperative assessment points. RESULTS Eighty-seven percent of patients reported satisfaction with their postoperative outcomes. Patients also reported significant improvements in their overall appearance, as well as the appearance of the feature altered by surgery, at each of the postoperative assessment points. Patients experienced significant improvements in their overall body image, their degree of dissatisfaction with the feature altered by surgery, and the frequency of negative body image emotions in specific social situations. All of these improvements were maintained 12 months after surgery. CONCLUSIONS These results add to a growing body of literature documenting improvements in body image following cosmetic surgery.

Risks and opportunities for plastic surgeons in a widening cosmetic medicine market: Future demand, consumer preferences, and trends in practitioners' services

Background: The American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery launched a joint Cosmetic Medicine Task Force to address the growing trend of non–plastic surgeons entering the cosmetic medicine field. The task force commissioned two surveys in 2007 to determine consumer attitudes about choosing cosmetic medicine providers and to learn about the cosmetic services that plastic surgeons offer. Methods: The first survey obtained responses from 1015 women who had undergone a cosmetic procedure or were considering having one within 2 years. The second survey obtained responses from 260 members of the two societies. Results: Compared with other practitioners, plastic surgeons enjoy higher rates of satisfaction among their patients who undergo noninvasive procedures. Injectables present a particularly promising market for plastic surgeons. Half of consumers surveyed said they were very concerned about complications associated with injectables, and generally, the higher the perceived risk of the procedure, the higher the likelihood that a patient would choose a plastic surgeon to perform it. In addition, injectables were among the noninvasive treatments most frequently being considered by consumers. However, almost half of consumers said that if they had a positive experience with a non–plastic surgeon core provider for a noninvasive procedure, that physician would likely be their first choice for a surgical procedure. Conclusions: These findings suggest that plastic surgeons, and especially those who are building young practices, must expand their offerings of nonsurgical cosmetic services to remain at the core of the cosmetic medicine field.

Digital clubbing: A unique case and a new hypothesis

A study of a unique case of unilateral digital clubbing secondary to a true posttmaumatic aneurysm of the ulnar artery in the palm is presented. The clubbing of the digits resolved following resection of the aneurysm. Detailed evaluation of the patient included Doppler flow studies, differential pulse pressure recordings, measurement of reactive hyperemia, angiography, and differential capillary blood gas determinations. The contralateral hand of this otherwise healthy young patient was employed as a control. Findings of increased blood flow, decreased peripheral resistance, and increased oxygenation then were evaluated in light of the findings of other investigators. This study and the information gathered from an extensive review of the literature strongly suggest that a neurocirculatory reflex is the common denominator of the various conditions associated with clubbing. The afferent and efferent limbs of this reflex are proposed.

Treatment of dyschromia.

Dyschromia can be distressing to patients and difficult to treat, whether it is related to skin-resurfacing procedures, surgery, hormonal changes, environmental exposure, or genetic predisposition. Stephen Mulholland, MD; Michael Kulick, MD; and Brooke R. Seckel, MD, address some frequently asked treatment questions posed by “Comparing Notes” editor Alan H. Gold, MD.

Treatment of the Nasolabial Folds

Dr. Jewell: One of the prominent signs of aging in the face is deepening and lengthening of the nasolabial folds. The goal of this discussion is to get your responses and ideas as to how a variety of patients would be treated for this condition. The first patient is a 71-year-old woman who is concerned about the appearance of her nasolabial folds (Figure 1) but does not want a face lift. Dr. Gold, what would you do for a person who does not want a face lift but wants an improvement in these areas? Figure 1. This 71-year-old woman is concerned about her nasolabial folds; she does not want a face lift. Dr. Gold: This is not an uncommon situation. I offer patients an algorithm of choices ranging from the simplest noninvasive treatments to the most involved surgical procedures. This patient has relatively good skin for a 71-year-old. Her asymmetrical nasolabial folds are a common finding. They are relatively deep. Her face is full and somewhat tense and shows relatively little subcutaneous descent of fat. Her midface and cheek contours are well maintained. There is no tear trough deformity, so I am not sure that she would even gain a significant benefit, surgically, from a procedure as invasive as a rhytidec-tomy. I do not think resurfacing would be applicable for her, at least not with her cheeks looking the way they do in this picture. Filling materials, which would be my first choice in most patients, would not be applicable in this case because the folds are too deep and the cheeks are too full. I would opt for some minimal lipoplasty of the anterior cheek, surrounding the fold, and then wide mobilization of the upper lip and the anterior cheek and fold, which can be performed through a small incision in …