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Getting Over Getting Under by Dr. Barry Friedberg

Five reasons why Dr. Barry Friedberg, a 36-year private practice, Board certified anesthesiologist and the founder and president of the 501c3, non-profit Goldilocks Anesthesia Foundation wrote Getting Over Going Under, 5 things you MUST know before anesthesia

Let no one ever kid you, being an advocate for change, especially in anesthesia, is about the most difficult task one could ever attempt to shoulder.

Hercules

     Hercules should have had it so easy.

 

 

In 1992-3, after seeing my first 50 cases of propofol ketamine (PK) sedation emerge without PONV or need for postoperative opioids, I felt much like Archimedes, “Eureka. I’ve found it.” PK numerical reproducibility was established with the addition of BIS/EMG monitoring in 1998.

I have published 5 peer reviewed papers, 15 letters to the editor in Outpatient Surgeon Magazine, more letters to the editor in Anesthesia & Analgesia, British Journal of Anaesthesia, Anesthesia Patient Safety Foundation, Plastic & Reconstructive Surgery, & Aesthetic Plastic Surgery, a landmark textbook ‘Anesthesia In Cosmetic Surgery,’ and 51 lectures in the US, Canada, Mexico, Dominican Republic, Israel, Malaysia & Singapore.

Many people publish papers. However, half of all published papers are never subsequently referenced. My papers have been subsequently referenced in 144 papers and in 50 textbooks.

Despite my Herculean effort to change the minds of my fellow dedicated anesthesia providers (DAPs), the subjects of postoperative pain management and PONV continue to appear in the literature as if the solution had yet to be discovered (or worse if my efforts had never occurred.)

As Aspect’s Dr. Paul Manberg often opined, ‘Change is glacial.’ When presented with my thoughts about getting better patient outcomes, most of my colleagues attitudes were essentially, ‘We’re not killing anyone, why should we change?’ Somewhere Semmelweis’ corpse is turning over in his grave.

Actually, as Li reported in 2009 Anesthesiology (110, 759-765), we are killing one American patient every day from anesthesia over medication, the natural result of not directly measuring anesthetic effect on the cerebral cortex. Even more saddening was that the editors of Anesthesiology did not deem this mortality study worthy of being an article of special interest.

Part of the human condition is that all people regardless of their profession resist change. Physicians as a sub-set are notoriously resistant to change. DAPs as a sub-set of physicians are virtually impossible to change. Unless presented with this simple paradigm in training, most DAPs will not even consider the notion of a differing paradigm.

The DAP syllogism goes like, ‘All surgery is painful. Opioids (narcotics) are painkillers. Therefore, all surgery requires the judicious use of some opioids.’ Having successfully practiced for the past 16 years without intra- or postoperative opioids, I would beg to differ.

Postoperative pain is a function of intra-operative pain.

Only by midbrain NMDA saturation prior to incision (or injection) does one avoid entrance of pain signals to the brain. NMDA saturation is accomplished in 98-99% of patients with a 50 mg dose of intravenous ketamine 3 minutes prior to stimulation. Hallucination free use of ketamine is accomplished by incrementally titrating propofol to BIS <75 with baseline EMG; i.e. tinyurl.com/n98x86k

Instead of being frustrated with my apparent inability to produce change in my fellow DAPs’ intra-operative conduct, I considered using the same paradigm for change that got fathers in the delivery rooms for the births of their children; i.e. public knowledge leading to public demand.

What are the 5 reasons I wrote ‘Getting Over Going Under, 5 things you MUST know before anesthesia?’

Reason #1: How can a pre-surgery patient know to ask for the best available technology, a brain monitor, if they do not even know that such as thing exists?

Reason #2: Why would they ask for one without the knowledge that over medication can lead to delirium, dementia and even death, especially in those over 50?

Reason #3: Why would the general public not assume they would receive the best available technology for their anesthesia care, especially if it might improve their chance of waking up without brain fog?

Reason #4: Why does PONV still exist and is there is an established way to avoid it?

Reason #5: Why does postoperative pain still exist and is there an established way to avoid it?

The answers to these reasons are easily digested in his 2010 book for which a free Kindle giveaway this summer was very successful and another is planned for this fall.

All proceeds from the sale of this book support the education message of Dr. Friedberg’s non-profit Goldilocks Anesthesia Foundation, “No major surgery under anesthesia without a brain monitor.”

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For further information, contact Dr. Friedberg @drfriedberg@drfriedberg.com

SAFE ANESTHESIA DURING COSMETIC SURGERY

Board certified anesthesiologist, Dr. Barry Friedberg and I have become well acquainted by now. I have been impressed with his innovations to his field, including a brain monitor device that monitors anesthesia levels for each individual to just the right degree. This is a potentially life saving feature – an important feature for those undergoing any surgery – cosmetic or not. 

Click here to watch this video.

It might save your life or that of someone you hold near and dear.

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I have written about this before and in more detail.

Click here for more.

Have a beautiful life!

Lois W. Stern

WHAT’S HAPPENING WITH STEM CELL FACE LIFTS?

Are you beginning to see ads for Stem Cell Facelifts? If so, I’m not surprised!  I too am convinced this is the wave of the not-too-distant future. But many of these Stem Cell Facelifts of today are simply fat removed from one part of the patient’s body and reinjected into other parts, as treatment for aesthetic concerns such as crows feet or mouth to jaw marionette lines. Fat transfer as such is nothing new in cosmetic surgery. It has been used by plastic surgeons since 1983 and is considered extremely safe, but not as long lasting as the fillers of today.

stem cells

But stem cell treatments are a bit different from simple fat transfer,  a refinement of the process if you will. In a true stem cell treatment, once the adipose tissue (the fat cells) are removed from the body, the actual fat is separated from the richer stromal vascular fraction (SVF) cells, which are far more potent than the remaining fat cells. Once separated from adipose tissue, they are reinjected  into the patient’s body without further manipulation. The SVF cells are neither cultured, further enriched or changed in any way.

My education on Stem Cells in Plastic Surgery began with noted plastic surgeon, Dr. Alan Kisner, when he wrote a chapter for my book: Tick Tock, Stop the Clock ~ Getting Pretty on Your Lunch Hour. He explained both the huge potential for the use of adult stem cells in medicine, but also the obstacles to its use:

“For the cosmetic surgery patient, fat seems like an ideal material for soft tissue augmentation, but it has been impermanent due to resorption. In order to become permanent, grafted fat must create it’s own blood supply.”

Dr. Kisner went on to explain how fat grafting, one technique being used to circumvent this problem, involves injecting small amounts of fat (less that 0.1 cc at a time) in discrete layers to gradually build new tissue layers. By allowing time and space between these microinjections, new blood vessels are able to grow within the grafted fat, enabling them to establish permanence. Aside from the skill and specialized training of the surgeon, he emphasized that fat grafting is a slow process that requires patience on the part of both patient and surgeon. In this same chapter, Dr. Kisner spoke about pioneering research now underway to separate the fragile stem cells, in order to enable them to more readily produce their own blood supply.

That said, you can see why this emerging technology of  SVF cells holds huge promise not only to the field of cosmetic surgery, but to the pioneering field of regenerative medicine, by enabling the body to repair, replace, and regenerate damaged, aging or diseased cells, tissues and organs.

Funny how things happen through connections over the Internet. I recently posted an article, Stem Cells in the News, where I spoke about a stem cell procedure gone wrong after a surgeon injected both stem cells and derma fillers into a patient’s face, causing a well-meaning but disastrous result. One of my readers, Jonathan Schwartz, commented that this was true stem transfer facelifts have not been FDA approved. We got into further conversations, spoke on the phone, and he subsequently sent me further material to digest. It turns out he is the President and CEO of MedicalMarvels LLC,  a company doing pioneering efforts in regenerative medicine.

A large body of scientific evidence suggests that adipose-SVF may act by replacing lost or damaged cells, reducing inflammation, improving the function of cells at the site, and recruiting cells from other parts of the body to assist in these processes.

There is at present no benefit is payable, either by Medicare or by a health fund for adipose-SVF treatment. You may be able to claim a tax refund of 20% of the cost, if your total health costs are above $2,000 in a year. We recommend seeking independent advice in this area.

Medical Marvels LLC is an emerging leader in regenerative medicine using adipose (fat) derived stromal vascular fraction containing adult stem cells for pioneering regenerative medicine.  Regenerative Medicine is a rapidly expanding set of innovative medical technologies that restore function by enabling the body to repair, replace, and regenerate damaged, aging or diseased cells, tissues and organs.

To date, this company has developed proprietary technology that allows for the efficient and reproducible separation of stromal vascular fraction (branded “Cellication”) containing adipose stem cells and extracellular matrix that can be performed in doctor’s offices, medical facilities and hospitals. This company is also engaging in clinical studies at major medical centers to obtain FDA approval for clinical indications.

Stay tuned folks. We haven’t heard the end of stem cell face lifts yet!

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STEM CELL FACELIFTS IN THE NEWS

stem cell

Three years ago a Los Angeles woman had a new cosmetic procedure, a stem-cell face-lift. During this procedure the surgeon liposuctioned adult stem cells from her stomach fat and after isolating them, injected those cells back into her face and around her eyes. In this case the doctors extracted mesenchymal stem cells—which can turn into bone, cartilage or fat, among other tissues—and injected those cells back into her face After some time, the woman was experiencing difficulty opening her right eye, and whenever she tried, she heard a strange sound. Eventually she consulted a second plastic surgeon, complaining of these symptoms. At first the consulting surgeon thought she was exaggerating, but she did indeed have a swollen, drooping eyelid. This was no overactive imagination at play! After more than six hours of surgery, the consulting surgeon and his colleagues had dug out pieces of bone fragments which had been growing in the flesh around the woman’s eye. The strange sound the woman was hearing whenever she tried to open her eye was bone grinding against bone.

Why did this occur? During the patient’s initial aesthete treatment, her surgeon had injected some dermal filler along with the stem cells. Although plastic surgeons have safely used dermal fillers for more than 20 years to plump up the skin and obscure wrinkles, the principal component of such fillers is calcium hydroxylapatite, a mineral which encourages mesenchymal stem cells to turn into bone, the probable explanation for this woman’s unanticipated predicament.

THIS STORY WAS REPORTED IN SCIENTIFIC AMERICA.

Although the consulting surgeon successfully removed the pieces of bone from his patient’s eyelid, no one can say for sure if her saga has ended as some living stem cells possibly have remained, to turn into bone in the future.

We all tend to get excited when we read about the next NEW thing to enhance our beauty. But MORE is not always better and NEW hasn’t yet stood the test of time. Cosmetic surgery is a constantly evolving field, but let’s be cautious and let the science precede the hype.

For more in depth information about Stem Cells, where we are now and where we are headed, read Dr. Alan Kisner’s informative article: STEM CELLS IN THE NEWS.

ANOTHER COSMETIC SURGERY HORROR STORY IN THE NEWS

I’m not opposed to cosmetic surgery. Not at all. Those who know me, know that I think it can be a pretty wonderful experience. But today’s headline in the Daily News; Hack plastic surgeon . . .  faces murder rap for performing liposuction on heart transplant patient made my skin crawl just a little.

 I wondered if this was a scare tactic, or if it was as bad as it sounded.  I had to find out so I read the full article. What I  discovered was that it was even worse than I had imagined. This plastic surgeon performed a cosmetic surgical procedure on a heart transplant patient without even consulting with her cardiologist. How could he even consider performing a non-essential surgical procedure on a woman with such a medical history? (I also wonder how that woman could have made such a foolish decision, but that’s a discussion for another day.)

I felt incensed! With all the competent, highly ethical plastic surgeons out there, doesn’t it make you wonder how this beautiful 51 year old woman fell into the hands of such an irresponsible one? I immediately went through my articles to find one I had written some time ago: How Do You Find the Surgeon Who Is Right For You.

So here is my plea to you today. If you are considering any type of cosmetic surgery, please do yourself a big favor and read this article first. It just might save your life!

knife

And if you want the details about this surgical horror story, you can read it here.

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BOTOX CAUSES BRAIN DAMAGE, SCIENCE OR HOGWASH? – PART 2

Last year, 4,329,180 aesthetic BOTOX® treatments were administered to women in the United States to relax their forehead frown lines. The side effects to these treatments have been minimal to non-existent. Slight bruising or swelling at the injection site, if any, has been found to resolve within twenty-four to forty-eight hours. Occasionally, an eye has temporarily drooped after forehead injections, but also resolves within a period of a week or two. But there have been no reports of any effects on the central nervous system. And as far as risk of death from Botox Cosmetic, the FDA confirmed that: There has never been a reported death where a causal link to BOTOX® (Botox Cosmetic) was established. But new fears about BOTOX® surfaced shortly after an Italian study reported in the Journal of Neuroscience revealed that when botulinum toxin, type A (the active ingredient in Botox), was injected into one side of adult rats’ brains, minute particles of protein in the toxin were found in the other side of the brain. The media went wild with headlines such as: Botox Causes Brain Damage.

Speak about false alarms and taking things out of context. If you are anything like me, the details will blow your mind! If you are interested in giving yourself a better education on this topic, I’ve done the hard work for you. Here’s the link to my article on Botox and Safety and many more.

Beauty Within

                Beauty Without . . .

                               What’s Your Passion?

Click to Explore the Many Dimensions of Beauty 

Lois W. Stern

WHAT CAN WE DO ABOUT THOSE AGING HANDS?

We’ve all seen it before, a young face, with old looking hands – the dead give away to a person’s age. The tell tale signs: wrinkled skin, brown spots, protruding veins, tendons and bones . . . An aging appearance is no longer measured just by facial lines and furrows, sagging jowls or waddle necks. As the public becomes more tuned to aesthetics, the appearance of the upper surface of one’s hands increasingly comes into play.

Why the Years Are Unkind to Our Hands

As we age, the fatty layer of our hands gradually thins. Our hands lose volume, fat and elasticity. As a result, the skin becomes more translucent and wrinkled, causing underlying structures as bones and veins to become more apparent. The elements of sun, wind and rain also are unkind to our hands. Hands constantly exposed to the sun develop brown spots. The drying effects of the elements cause further skin wrinkles.

 What’s a Person to Do?

Many surgical and non-surgical treatments are available to rejuvenate both facial and body features. What solutions can science offer us for aging hands? Let’s start with the basics.

Protect your hands from the elements by wearing gloves during times of inclement weather.

Apply sunscreen, ideally SPF 50,  to your hands several times during the day. Remember, each time you wash your hand, you are also washing away the protective sunscreen. So carry a small size sunscreen in your purse and reapply it often.

Moisturize your hands as well as your face with a good quality moisturizer.

Get rid of age spots:

Prescriptive strength hydroquinone or Retin-A help erase signs of hyperpigmentation. If these products don’t do the trick, lasers would be the next step up in treatments.

Get rid of the translucent, shriveled appearance of the skin on the top of your hands:

Dermal fillers  – synthetic ones such as Radiesse, Juvederm or Perlane or non-synthetic ones and non-synthetic ones as the patient’s own fat – are one viable solution. Injected under the first layer of the skin to plump it up in a 5-to-10-minute procedure, fillers work very well, but must be repeated as their effects diminish over time. A second solution is energy driven devices as intense pulsed light, Fraxel or CO2 laser resurfacing.

What about surgical hand lifts?

Can excess skin be surgically removed? Not anytime soon. For one thing, hand surgery is likely to causes obvious scarring. Secondly, hands pose a greater risk of complications. And beautiful hands would be a poor trade off for hands that don’t function as they should. In an earlier article I wrote about Madonna’s Eyes – how young and beautiful they appear.  But have you noticed that she often wears fingerless gloves during her performances – most likely to hide her less-than-young-looking hands?

Can’t science do something more for aging hands? Not at the moment, but never say “Never”.  Advances in cosmetic surgery are driven by demand, and hand rejuvenation is a hot new topic.

Beauty Within

                Beauty Without . . .

                               What’s Your Passion?

Click to Explore the Many Dimensions of Beauty 

Lois W. Stern