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.

Lupus is a rheumatic condition which affects the muscles, joints, and connective tissue. About 1.5 million people in the US have lupus which includes as many as 10,000 children. Nearly 90% of those diagnosed with lupus are female. It's an autoimmune disease. A healthy immune system produces special proteins or antibodies and these normally protect the body against bacteria and viruses that cause infections. In the case of lupus, the immune system confuses the body's healthy cells and sees them instead as if they were a bacteria or a virus, and the result is that our antibodies then attack some of our own body's healthy cells. You become allergic to yourself.

So, what causes lupus? The cause is unknown although genetic factors may be important. Certain things can trigger the disease such as infection, medications, and even extreme physical or emotional stress. There are different types of lupus; the commonest is something called systemic lupus erythematosus or SLE and this affects multiple organs, and there is also form known as discoid or cutaneous lupus which only affects the skin, and in as many as 10% of all lupus cases, they're classified as drug-induced lupus.

Systemic Lupus Erythematosus (SLE) is an autoimmune disease where self generated antibodies attack different organs systems in the body including blood vessels, liver, eyes, kidneys, joints, heart, heart valves, skin, lungs, brain...and/or form complexes with their protein targets (antigens) that damage these organ systems. The degree of damage to each organ system is highly variable. Arthritis and joint pain is the most frequent complaint. It is thought to be due to a genetic predisposition combined with viral infections. The disease can spontaneously remit, respond to corticosteroids or be unresponsive to available medications. 50% of those with SLE have some degree of heart and/or kidney involvement. Much of this organ damage can be masked and then suddenly become apparent especially during flare ups of the disease. I am aware of one women in her 30s who died in the recovery room after breast augmentation by another surgeon due to a heart attack caused by SLE induced damage to her coronary arteries.

So, what are the symptoms that are commonly associated with lupus? There are many. Classically, there will be butterfly rash. This is a rash that is across the cheeks and the bridge of the nose. There may be sensitivity to light that results in a rash. Also there can be ulcers in the nose or mouth, which are usually painless. There's a long list of many other symptoms that are associated with lupus including things like arthritis, inflammation of the lining around the organ such as the heart and the lungs, kidney problems. There may also be neurological disorders including problems with seizures or even psychosis. Blood problems and problems with the immune system are also found in lupus. And in addition to that, there are some nonspecific symptoms such as fever, weakness, fatigue, and weight loss. There is no known cure for lupus but the symptoms can be controlled with drugs, for example steroids, and sometimes more aggressive treatment is needed with immunosuppressive therapy.

Therefore it is imperative if you have systemic lupus that you have a complete examination of all major organ systems before undergoing any elective cosmetic surgery. This may include cardiac stress testing and blood tests for liver and kidney function. If you cannot be weaned off of prednisone that may be an ominous sign and may preclude any elective cosmetic surgery especially if any implants are involved.

If you are taking prednisone for lupus the medication can also prolong the healing time after surgery and weaken your ability to fight infection so proceed with caution before undergoing any elective cosmetic surgery.

For detailed information, support groups and to live the fullest life that you can with lupus visit the Lupus Foundation of America and the Lupus Research Institute.

(UPI) — A new California law will prevent doctors from performing elective cosmetic surgery without an “appropriate” physical exam, authorities said.

The law, which takes effect Friday, is named the “Donda West Law” after singer Kanye West’s mother, who died a day after cosmetic surgery in 2007.

The law requires “an appropriate physical examination within 30 days of a procedure and “written clearance” from a doctor, nurse practitioner or physician’s assistant before cosmetic surgery is performed, The Sacramento Bee reported Saturday.

The law will change little since reputable cosmetic surgeons have always obtained a patient’s medical history and made sure the patient had a physical exam before a procedure, said Dr. Terry Zimmerman, head of the Greater Sacramento Plastic Surgical Society.

Autopsy results showed Donda West died of pre-existing coronary artery disease and “multiple post-operative factors” a day after she had an abdominal tuck, breast surgery and liposuction. The surgeon who operated on West surrendered his medical license in April.

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