Anxiety disorders in plastic surgery

Surgery is a stressful event, with the potential for profound disturbance to the patient's psychological and physiologic homeostasis. Cosmetic surgery is a particularly intense psychological experience because, in addition to the usual concerns about surgical side effects, cosmetic patients bring their hopes and expectations for improved self-image, putting them at risk for the added anxiety of disappointment. High levels of anxiety coupled with the perception of vulnerability or threat to self can cause significant psychological reactions complicating care for the plastic surgical patient. This paper outlines the diagnostic features of the common types of anxiety disorders seen in plastic surgical patients, and it offers treatment strategies for the practitioner, delineating when referral to a mental health expert is advised. Specific clinical case studies of panic attack, posttraumatic stress disorder, and acute stress disorder are presented to illustrate the variety of abnormal anxiety responses that may be encountered in the perioperative setting. Interventions for the anxious patient are part science and part art. Careful questioning and psychosocial assessment can identify those patients who are at greater risk for psychological problems after surgery. However, some patients may mask or keep secret their concerns, which can be manifested with resulting anger and hostility. Plastic surgeons must use appropriate indicators of psychological anxiety and measure a specific patient's reactions to surgery to make the diagnosis of abnormal anxiety. Close follow-up by the plastic surgical team is an essential part of the anxiety disorder patient's psychological treatment, but it is imperative that these problematic patients be referred promptly to a qualified mental health professional to limit their adverse experience and promote their well-being. Patients who are less anxious during the perioperative period report less emotional distress and fewer defensive behaviors and are likely to be more satisfied with the outcome of their surgery.     

Computer-based multimedia in plastic surgery education

Computer animation complements text explanation, image documentation, and graphic analysis techniques. It is compatible with the development of interactive multimedia science. Computer animation may emerge as a critical tool to assist in the efficient processing and analysis of greater volumes of educational data in plastic surgery training. At St. Louis University, we have continuously developed multimedia plastic surgery teaching materials with full-fidelity digital sound, three-dimensional computer graphics, and "picture-in-picture" video capabilities since 1987. We have used these materials, many of which are illustrated in this paper, for patient informed consent and the education of medical students and residents.     

Anaesthesia in a plastic surgery unit before the Fall of Saigon

The staffing and anaesthetic techniques in use at the Children's Medical Relief International Plastic and Reconstructive Surgery Unit in Saigon between 1972 and 1975 are considered. The special value of the use of spontaneously respired trichloroethylene and halothane with air enriched with oxygen on the draw-over principle is discussed.     

Lasers in plastic surgery: current practice

A wide variety of lasers provides the plastic surgeon with treatment options that were not available previously. Appropriate, safe use of lasers complements the many therapeutic treatment options available to plastic surgeons. Lasers have introduced a new therapeutic modality. Because of the ways the skin and its defects may be altered with lasers, they will be an increasingly important part of plastic surgery.     

von Willebrand''s disease and plastic surgery

Von Willebrand's disease (VWD) is the most commonly inherited coagulopathy. In a group of 1,000 plastic surgery patients, 8 or 9 individuals are affected by this disease, making basic knowledge of VWD and its management imperative. In this investigation, 1,000 plastic surgery patients were studied for details of their clinical evaluation, history of bleeding and bruising, and excessive bleeding during or after surgery. If the patient reported a history of easy bleeding or bruising, in addition to routine coagulation studies such as PT, PTT, and platelet count, the bleeding time was measured. When the index of suspicion dictated, more extensive coagulation studies, such as factor VIII assay, were conducted. This resulted in the detection of VWD in 9 patients (8 female and 1 male). All patients had a positive history of easy bleeding or bruising. Six of the 9 patients had a bleeding time greater than 6 minutes. Seven patients were diagnosed to have VWD type I, 1 had type II-a, and 1 suffered from type II-b disease. Perioperative bleeding was controlled in all patients in this study with the administration of 0.3 microgram/kg of body weight (usually a total dose of 20 micrograms) of 1-deamino-8-D-arginine-vasopressin intravenously every 12 hours for the first 24 hours. Two patients with type II VWD required fresh frozen plasma and cryoprecipitate 1 week subsequent to surgery to control late bleeding.     

Competitive forces and academic plastic surgery

Economic constraints developing as a result of rising health care costs in the United States pose significant challenges for and threats to the survival of academic plastic surgery. Declining clinical revenues, competition for patients and resources from other health care providers, and reductions in support of its education and research efforts necessitate a paradigm shift if it is to survive. Questionnaires were used to collect data from 92 of the 100 postgraduate training program directors of plastic surgery in the United States. The most common source of clinical income on a national basis was indemnity insurance. Sources of clinical income varied by region. The majority of programs, 80 percent, report that at least 75 percent of the income support for faculty came from practice income. Financial support for ancillary and research personnel, in large part, came from this same source. Resident salaries and benefits came largely from other resources. Generally as population density within the metropolitan area in which a program was located increased, so too did the number of competing plastic surgeons, including graduates of the program and nonacademic cosmetic and hand surgeons. However, levels of competition for cosmetic surgery in smaller metropolitan areas of some regions seem to be similar to those reported by programs in larger communities. Plastic surgery programs in very competitive communities received significantly greater amounts of their income from indemnity insurance and self-paying patients than did programs in less competitive metropolitan areas. Internal competition from other surgical and nonsurgical specialists within the same institution is likewise keen. Virtually all respondents, 93 percent, report that their institutions provided patient care in a least one designated center of excellence in the following disciplines: hand, microsurgery, craniofacial, cleft lip and palate, burn, and cosmetic surgery. This study suggests that centers of excellence are more likely to be present in metropolitan areas with fewer competing surgeons than in areas with large numbers of competing surgeons. The data did not demonstrate that the presence of a center of excellence substantially affected the sources or levels of clinical income. To survive as an academic entity, program directors must correctly perceive and fulfill the needs and wants of its stakeholders, particularly with regard to quality of life issues.     

Application of endoscopic techniques in aesthetic plastic surgery

Although plastic surgeons had been slow to incorporate endoscopic techniques into their surgical armamentarium, there has been considerable interest in this field during the last 2 years. The aim of endoscopic brow lifting has been to achieve elevation of the brow through small scalp incisions without the associated nerve damage of the open approach and to accurately address excision of the muscles responsible for frowning. Endoscopic neck lift is a more recently pioneered technique which, although still in developmental stages, appears to provide good results. The technique involves undermining the skin of the neck extending from the chain to the jawline around the ear. Endoscopic facelifting is still very much in the experimental stages. Endoscopic techniques reduce the need for an incision in front of the ears. Using the endoscope, it has become a simple matter to perform a transaxillary breast augmentation using very small axillary incisions and precise placement of the implants. This results in excellent symmetry postoperatively and easy scar concealment. Abdominoplasty is another example of a procedure usually associated with a long incision and some degree of postoperative pain and immobility. Endoscopic abdominoplasty has been devised to provide not only contouring of abdominal fat through liposuction, but correction of the weakened abdominal muscle through a small incision placed just above the suprapubic hairline.     

Status quo of plastic surgery education in Austria

Quality is essentially based on excellent training. Therefore, all medical disciplines in Austria, including the Plastic Surgery, have to orientate on EU-standards including efforts to adapt the surgical training. To gain an overall impression of the present training situation in Austria, an anonymous questionnaire was sent to all the 25 trainees in Plastic Surgery in summer 1995. Eight centres were involved throughout the country. The questions covered quality of training, reference departments, rotation in training, and postgraduate studies, 52% of the questionnaires were sent back. The conclusions resulting from the questionnaires are the following: unrestricted passing of plastic surgery know-how, provision of reference departments, implementation of rotation for training, carrying out of all operations listed in the EU-catalogue, regular postgraduate training. Only in this way excellently trained plastic surgeons with a strong self confidence can be a convincing counterpole to other fields of surgery which increasingly lay claim to Plastic Surgery terrain.