Florida Teen's Cosmetic Surgery Death Explained

Since yesterday, there have been many reports and comments about the Florida teenager who died during  breast augmentation surgery.  Some report highlights:

• Malignant hyperthermia, the cause of death, is hereditary and thus any patient undergoing GENERAL anesthesia should be asked: "Family history of problems with anesthesia?" If so, there is a diagnostic test available


• MH, very rare, but reversible if detected early and treated aggressively. Every anesthesia specialist and surgeon should know the management.


• An accredited, licensed or certified surgical facility, whether hospital, outpatient surgery center or office facility is required to have the specific antidote, a drug called Dantrolene, on the premises for emergency use.

What we know, so far, is that the 18-year old Florida patient developed the very rare complication of general anesthesia, malignant hyperthermia, literally "dangerous elevated temperature". But the temperature, per se, is not the only, nor typically the first, sign of this acute erroneous error of muscle metabolism. It is merely the most striking sign because few other elements of surgery or anesthesia will generate a high temperature in the middle of an operation.

While the patient's pre-disposition is hereditary, because of the condition's rarity, few patients can report a family history. Therefore, unless suspected, the condition arises without warning during surgery.

Here are the classical signs of malignant hyperthermia:

1. Sudden and otherwise unexplainable RAPID and STEEP rise in the pulse rate, e.g from 80 to 150 within minutes.


2. Rapid rise in breathing rate.


3. Major temperature elevation, which usually follows the above. Can rise to 106 F or more.

Think in terms of a marathon runner. The muscles are working overtime and the body attempts to self- regulate by automatically increasing heart and breathing rate and the temperature rises to "cool down" the body.

In malignant hyperthermia, the muscles are working overtime but not carrying the patient anywhere.

The immediate treatment is well-established. The general anesthestic agent, is "turned off"; 100% oxygen is driven into the lungs. To stop the muscles' hyper-metabolism, a drug, Dantrolene -- specifically used for malignant hyperthermia -- is given intravenously. The body is cooled by packing in ice and the patient is transported to a hospital intensive care unit.

The key to successful treatment and saving the patient's life is early recognition by the surgeon and anesthesia specialist. Because most anesthesiologists have not seen a case in their careers, they must carry a high index of suspicion when the computerized monitors' warning lights and bells suddenly go off for no apparent reason.

Appreciation to Kevin Tehrani, MD, Chief of Anesthesia at the Summit Surgery Center, Beverly Hills, CA., for his input. In preparing this, I consulted with Dr. Tehrani whom I recalled had successfully treated a case of malignant hyperthermia at the USC-LA County Hospital.

Related Topics:

• Guide to Breast Enlargement Surgery
  
• Breast Implant Safety
  

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Peels, Lasers and Microdermabrasion? Which is Best?

What is the difference between the non-surgical skin treatments: peels, lasers and microdermabrasion? How do you select the best one for aging skin?

With over 100 treatments now available, it is daunting to know what is best for your skin.

"Light" Chemical Peeling Agents

Alpha-hydroxy Acids: These mild peeling agents act as a deep exfoliant removing the dead cells from the skin surface and accelerating the maturation of the remaining cells. The aim is to make the skin smoother to the touch and more lustrous in appearance. The most commonly used alpha-hydroxy acids are lactic acid, glycolic acid and citric acid. Alpha-hydroxy acids (in concentrations of less than 10 percent) are used in cosmetic preparations; in concentrations of 10-70 percent, as skin peeling agents. In antiquity, women bathed themselves in sour milk in the hope of softening and smoothing the skin. Perhaps they understood intuitively that sour milk contains lactic acid, now used for, the same purpose.

Medium Strength Chemical Peels

The most common medium strength agent is trichloroacetic acid ("TCA"). Typically used in concentrations between 20 percent and 50 percent, TCA, a strong acid, destroys the epidermis (the outer layer of skin) and penetrates into the dermis (deeper skin). As a result, it stimulates the formation of new, fresh skin that is richer in collagen and elastic fibers, and is more taut with fewer wrinkles. Trichloroacetic acid has been used by experienced practitioners for many years. Because of the strength of this chemical and the possibility of complications, TCA skin peels should be performed only by experienced dermatologists and cosmetic surgeons. Anesthesia may be required for patient comfort and safety. This process of skin rejuvenation may take five to seven days of "down time" after which the skin is red. Cosmetics are required until the red color fades. When red, the skin is extremely sensitive to the effects of the sun and, therefore, a comprehensive skin program emphasizing sun protection is mandatory.

The "Heavy Hitters"

Deep Phenol Peels

"Phenol peels," the so-called "heavy weights" of skin rejuvenation, have a long and successful history. They have been performed in the U.S. as a mainstream procedure since the early 1960's.

Phenol is an acid-like chemical that, when mixed with other agents, becomes a potent prescription, resurfacing the skin by removing wrinkles, crow's feet, age spots and other superficial skin imperfections. Experienced practitioners regard phenol formulations as the standard against which all other skin resurfacing procedures must be measured.

Because of its ability to penetrate to the deeper layers, there may be some permanent lightening of the skin.

Laser Peels

• Nd:YAG (Neodynium) laser: penetrates below the outer layer of skin, stimulating fresh collagen without causing a destruction of the outer-most layers. This translates into a shorter healing time. But this procedure, because it is less intense, requires maintenance treatments and has not lasted as long as the other laser treatments, and may not last as long as other laser treatments.
• Carbon Dioxide (CO2) laser: The first widely utilized skin laser, introduced in 1995. Strongest, most invasive laser. Less popular today because of high percentage of over treatments (think complications) and undertreats (think disappointed patients).
• Fraxel Laser: Less invasive, faster healing. Good for improving sun damaged skin, spider veins, age spots and some acne scars.

Skin Rejuvenation Technology

• Titan®: Light flashes purportedly restructures the dermis to tighten the skin without surface changes.
• Thermage®: Radio frequency technology. Superheats the skin and claims to thereby tighten the skin by strengthening the collagen. Little down time, but reports of a very high percentage of disappointed patients.
• Plasma Energy New: Claims resurfacing of the skin to "reduce wrinkles and improve skin tone and texture". Further evaluation is needed.
• Intense Pulse Light (IPL): Flashes of light to reduce spider veins, pigmentation, also employed against acne. Has been well accepted with very low complication rate.
• Microdermabrasion: Gentle sandblasting to smooth the lines and lighten age spots and other signs of skin damage. A minimal treatment.

Note: This list is not intended to be all-inclusive. I have chosen a variety of the more popular and/or promising treatments so that one may understand the variety in procedures and technology available today.

Related Topics:

• WebMD Video: Peel Away Wrinkles
• Age-Fighting Skin Treatments for Men

Technorati Tags: cosmetic surgery, peels, lasers, microdermabrasion, aging skin