Sharmeen Obaid-Chinoy was born in Karachi Pakistan, emigrated to Toronto, Canada and this passed weekend won an academy award here in Los Angeles for her short documentary film Saving Face. The film documents the plight of Pakistani women who are disfigured by having acid poured on them usually by relatives, husbands or rejected suitors. The acid damages the skin, sometimes exposes the underlying bones and often times causes blindness in one or both eyes. The film chronicles the efforts of a Pakistani born British plastic surgeon, Mohammad Jawad,  to reconstruct their faces and restore their dignity. It is the first win for a Pakistani film. A win that instills pride and shame at the same time. Over 100 such attacks occur in Pakistan each year. Most go unreported and the women live secluded lives due to the circumstances surrounding these attacks (in the case of husband attackers they do so out of fear for their children) so the number of victims could even be double that. In the course of the film a girl describes being burned at age 13 for rejecting the advances of her teacher. In the Western world that teacher would have been prosecuted. Although it is rare a female Pakistani lawyer took up the legal case of one of the victims in the film and successfully managed to have the perpetrator convicted. Sadly these women require multiple operations to regain some resemblance of normal appearance. There is a report of a New Delhi India girl who underwent 25 reconstructive operations to treat disfiguring from acid burns.


The woman in the trailer with the severely disfigured face had acid thrown on her face by her husband after she had filed for divorce. It was almost as if half her face was wiped out. What was left was one eye, half a nose and a mouth that couldn't smile. The prosthetic face mask she was fitted with was voluntarily made by Dubai-based Indian anaplastologist Daril B. Atkins

The film will debut on HBO television March 8, 2012.

A few random such attacks have occurred in the West such as the 2008 attack of a London England model and TV presenter Kate Piper who sustained an acid burn of the face inflicted by an ex-boyfriend and his accomplice. Those 2 men are now serving life sentences in a British prison. Pakistan's Lower House of Parliament unanimously ratified the Acid Control and Acid Crime Prevention Bill On May 10, 2011. The bill calls for life imprisonment of assailants but to date prosecutions have been minimal.

Pakistan's prime minister, Yusuf Raza Gilani, said Pakistan would confer on Obaid-Chinoy "the highest civilian award upon her return".

"Pakistan is reportedly the third-most dangerous country in the world for women after Afghanistan and Congo...". It was only a few years ago that there was a Time magazine cover photo of a young Afghan woman whose nose was cut off in retribution for a similar attack.

Pain control during surgery has been quite good for a number of decades. Refinements in recovery from anesthesia to lower the incidence of nausea, shaking etc. after surgery have been accomplished by adjusting the mix of anesthetics used and employing newer medications like propofol, toradol, zofran etc. More recently the focus has been on controlling pain after surgery to lessen the need for narcotics, shorten recovery times after surgery and improve surgical results in general. The opioid narcotic medications commonly used can become addictive, have small windows between effective and overdosing quantities that affect breathing and tend to be constipating.
Local anesthetics have been in regular use since the late 1800s. Most people currently get their exposure to them at the dentist office where novocaine also called lidocaine is injected prior to dental work. The onset and duration of action varies between different local anesthetics. Novocaine is one of the quickest onset and shortest acting local anesthetics. About 10 years ago surgeons began using longer acting bupivacaine applied via external pumps and tubes like the on-Q system to the operative site as a means of pain control after surgery.
The thought was that slow constant administration of a long acting local anesthetic to the operative site would allow for a quicker recovery after surgery, allow the patient to get up and around earlier and decrease the need for narcotic pain killers after surgery. Their use became especially popular with orthopedic surgeons who would place the catheters directly over bones or into joint spaces after surgery (such as knee or shoulder surgery) and to a lesser extent with general and thoracic surgeons. In 2007 it was discovered that prolonged exposure of joints to local anesthetic caused permanent loss of cartilage in the shoulder joint and multiple lawsuits have been filed since. Currently, there is no effective treatment for cartilage loss; patients who have experienced it have required additional diagnostic and therapeutic procedures and some required arthroplasty or shoulder replacement. Use among plastic surgeons was more limited and confined mostly to tummy tuck and breast surgery patients to decrease reliance on pain medications and allow for earlier ambulation after surgery. I tried this in the past on tummy tuck patients and was unimpressed by its ability to do either so I stopped doing it.

In October, 2011 the FDA approved Exparel which has just recently become available for public use. Exparel is long acting bupivacaine that has been placed in a container of microscopic fat cells. The anesthetic is then slowly released from the fat cell container into the body after injection. This extends the effectiveness of the anesthetic from a few hours up to 3 days. EXPAREL is the first and only multivesicular liposome-based local anesthetic that can be used around surgery in the same fashion as current local anesthetics. The medication is injected near the end of surgery and should not be injected with other local anesthetics at the same time as that could result in sudden release of all of the anesthetic from the fat cell containers. In clinical studies exparel was most effective in the first 24 hours after surgery. The fat cell containers can be damaged by contact with the liquid antiseptics commonly used just prior to surgery.

Due to the large surface areas involved in body contouring surgery like breast surgery and abdominoplasty I suspect this medication will prove most useful for rhinoplasty, facial implant, ear and hand surgery. Clinical studies have shown this medication to be most effective in the first 24 hours after surgery and to significantly reduce the need for narcotic pain medications after surgery.

I think we will see many more fat cell packaged medications in the future.

Obstruction to airflow in the lungs can be due to
fixed or irreversible lung disease (COPD)reversible (responsive to medications) obstruction due to heart failurereversible (responsive to medications) obstruction due to asthmaThe obstruction can be due to just one of the factors or any combination of 2 or more factors.

In asthma the walls of the breathing tubes into the lungs swell (become inflamed), muscles surrounding the tubes contract squeezing the tubes and then increased mucus secretions inside those tubes plugs them. This results in obstruction to airflow with audible wheezing and a tight feeling in the chest as the individual tries to get the air through narrowed plugged tubes. Attacks can be mild resolving quickly with medication or severe and life threatening.

Attacks of asthma can be stimulated or triggered by environmental factors like pollen, cigarette smoke, dust mites, pet hair, insect excretions, air pollution, stress, exercise, infections etc. The trigger can be something you are allergic to. The primary medications used to treat asthma are bronchodilators which counteract the muscle spasm and steroids which treat the inflammation.

For the asthmatic undergoing cosmetic surgery an attack can be triggered by irritation from the breathing tube in general anesthesia, dehydration associated with any surgery, inability to clear secretions while lying down under the influence of anesthesia or even pain medications used during surgery. The anesthesia staff needs to adjust the medications given in such situations and the patient needs to bring their inhaler with them to surgery, if they have one. If they patient smokes it is imperative that they not do so for at least one week prior to surgery. Cosmetic surgery in an asthmatic who was smoking within days of surgery is a dangerous combination as they are very sensitive to asthmatic triggers.

Abdominoplasty and belt lipectomy patients who are asthmatics are at higher risk of attacks because the immobility after surgery combined with greater pain medication needs.

The steroids used to treat inflammation in asthmatics also prolong the healing process so sutures may have to stay in longer than they otherwise would. The adverse affect on healing can be reversed by taking Vitamin A before and after surgery. The vitamin does not affect the anti-inflammatory effect so it will not exacerbate the asthma.

This is a tricky situation because even if normal lung function tests and a normal physical examination an asthmatic attack can occur due to any of the factors mentioned above. Furthermore, significant impairment of lung function can occur in asthmatics without symptoms. The history and general physical examination may not accurately indicate the severity of the asthma. The answer is not to just do the surgery under local because you think it would be safer. If you have an asthmatic attack induced by a cosmetic procedure and cannot have a breathing tube placed because of the spasm you will not survive. The answer is to do the surgery in an environment where should any of these problems arise the right personnel and equipment are present to handle the situation. Certified operating rooms will have the necessary oxygen, IV fluids, inhaled and injectable bronchodilators, oral and intravenous anti-inflammatory agents to treat an attack. It is highly unlikely that a non-certified operating room will have those medications.

Only asthmatics with stage I disease and an forced expiratory volume greater than 75% of predicted values can undergo surgery without a higher than normal risk of airway complications. Any asthmatic who has taken steroids, whether orally as a pill or as an inhaled medication, within 6 months of surgery needs perioperative steroids to cover for diminished adrenal function. Inhaled steroid medications may have to be temporarily replaced by oral prednisone until the patient has recovered from surgery. Any asthmatic with audible wheezing should not be having elective non-emergent surgery.

I am personally aware of a fit individual in his 30s who went to a martial arts practice session without his inhaler. He suddenly developed an exercise induced asthmatic attack. By the time the ambulance and paramedics had arrived he could not be revived and passed away. Prompt use of an inhaler would most likely have circumvented this. A similar situation could just have easily occurred with cosmetic surgery.

I was performing non-cosmetic reconstructive surgery on a healthy 20 year old patient in the hospital. He was asleep on the table and just as I was about to make the first cut the monitors showed the oxygen in his blood suddenly dropped to dangerously low levels. Anesthesia went into action and gave him a bronchodilator using an inhaler via the breathing tube. He rapidly responded and the oxygen came back to normal levels and was maintained there using intravenous medications. In a non-accredited operating room lacking all of the necessary equipment and medications that patient would have been in real deadly trouble. There is a good chance he would not have survived a liposuction procedure under local anesthesia in a non-certified operating room. Furthermore, that patient was previously thought to be healthy and had no previous history of asthma.

The botulinum toxin is widely recognized for its ability to decrease the appearance of wrinkles in cosmetic surgery. What many people may not know is that it also has a number of health benefits as well. Hospitals in India are currently using the drug as a treatment for cancer patients who have lost their voice due to throat cancer. Patients undergoing cancer treatment undergo a removal of the voice box as a part of the treatment necessary to remove the cancer.

Tata Memorial Hospital is one hospital that is currently performing the procedure on patients who are suffering with severe voice problems after cancer treatment. The treatment helps patients that are unable to benefit from an artificial voice box. For some patients, the treatment helps patients produce sound after doctors remove the voice box due to cancer. Ninety percent of patients who undergo the removal of their voice box will be treated successfully with an artificial voice box. For the remaining ten percent, the voice box does not restore sound.

The treatment is done by injecting the chemical directly into the vocal chords that will help in the muscle relaxation in order to relieve problems such as difficulty in speaking, stammering and strangled quality of voice. The frequency of the dosage required is determined by the doctor after a post-treatment checkup.

Patients must undergo tests to determine the cause of the prosthesis failure. If it is determined that a hyperactive or hypertonic pharyngoesophageal segment causes the artificial voice box failure, the Botox injection procedure can take place. The physician must also determine the length of the hypertonic segment. The injections are made into the segment at 1 cm intervals. Patients may see results in as few as 12 hours after receiving Botox injections.

Botox injections can also treat patients without cancer who have lost their voice because of laryngeal dystonia which causes the vocal chord to spasm. Physicians inject Botox into the muscles that surround the voice box to relax the muscles and allow vibration and sound to occur.

Botulinum toxin has been studied for more than 100 years and in the last 20 years a number of health issues have been treated with the neurotoxin. Botox has been used to treat cervical dystonia, muscle spasms, muscle pain and underarm sweating in addition to the treatment for voice box problems. There are currently 21 medical uses for the neurotoxin in 80 countries, with research continuing to uncover possible new uses.