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IV 3000 Fingertip Wound Protocol

INTRODUCTION:

Distal fingertip trauma and pulp amputations have traditionally been treated by hand surgeons with surgical skin grafting or local flap coverage. The IV3000 (Smith and Nephew) is a transparent semi-permeable synthetic dressing that improves wound healing. Its Moisture Vapor Transmission Rate (MVTR) is six times higher than other permeable dressings.  This gradient creates the necessary wound micro-environment that facilitates re-epithelialization without maceration. This environment includes: appropriate moisture and temperature levels, macromolecules(GAGs, proteoglycans), growth factors(macrophage and platelet derived), and protection from external pathogens. The IV3000 is minimally adherent due to its grid adhesive spread. This results in reduced pain during dressing changes and less disruption of neo-collagen formed in the wound bed.

OVERVIEW:

– Assess fingertip injury for possible surgical indications:

Prominent or degloved bone at fingertip

Nail bed laceration

Tendon injury

Open DIP joint laceration

Other finger/hand injuries requiring surgery

– If no indication for surgery proceed with IV3000 therapy

 

IV 3000 (standard) INSTRUCTIONS FOR APPLICATION (See Video)

 

– Equipment required:

Dressing pack, scissors

IV 3000 (standard) dressings x2 (NOT TEGADERM)

Band-Aid

 

– STEP 1

Clean and dry the injured finger

Lay one IV 3000 on a flat surface with sticky side UP

Place the finger onto the dressing

– STEP 2

Place the other IV 3000 sticky side DOWN to “sandwich” the finger tip

Press the sides of the IV 3000 dressings together to seal the finger

– STEP 3

Fold the excess IV 3000 edges under the finger

Use Band-Aid to reinforce the finger tip (do not pull too tight on the tip)

 

FOLLOW-UP CARE

Patients with isolated finger tip injuries treated with IV 3000 can be discharged home from the Emergency Department with simple analgesia

 

The need for oral antibiotics and tetnus booster should be assessed on an individual case basis, considering the mechanism of injury and initial wound contamination

 

The IV 3000 can get wet in the shower then gently dried, but care should be taken not to displace the dressing. Seek a replacement dressing if required.

 

Change IV 3000 dressing every 3-4 days or as needed.

Wash finger in soap and water. Pat the wound dry and then reapply the IV 3000 sandwich and bandaid.

 

Allow protected use and encourage movement of the finger.

 

OTHER

 

Note that Tegaderm™ and other clear synthetic dressings are NOT an adequate substitute for IV 3000 for these injuries.  They are significantly less “semi-porous” with a lower MVTR which may cause maceration of the surrounding normal skin and complicate wound healing.

 

Soft tissue and cancellous phalangeal bone can granulate and heal with this technique. If exposed viable bone protrudes beyond the tissue plane it should be resected back to be level with that tissue.

The PIP joint should not be included in the IV3000 sandwich in order to encourage movement of the finger and prevent stiffness.

What is Plastic Surgery Reconstruction after Moh’s Surgery?

by W. Thomas McClellan MD FACS    McClellan Plastic Surgery

I often get stopped in the hospital, on the street, or even in StarBucks to look at moles. Patients want to know if a mole is dangerous and what they should do about it. Can I remove the mole? Should they see their dermatologist? What is the best option?

I will address the skin cancer as a whole in another blog post but wanted to talk specifics about Moh’s Surgery, reconstruction of the resultant defect, and the importance of a close knit team in order to get optimal results.

Moh’s surgery is essentially a “real time” evaluation of the complete surgical margin as the skin cancer is removed from the patient. The Moh’s physician is a specialized dermatologist who removes the skin cancer tissue and also acts as the pathologist reading the “slide” under a microscope. This method has a cure rate of about 97%. Moh’s excision of skin cancer is most commonly performed on structures that hold critical value and where excessive resection of tissue is detrimental. Examples of these locations include the eyelid, nose, ear, and cheek.

Here is a Wikipedia link to read a more in depth description of Moh’s Surgery Moh’s Surgery Wikipedia

So why and how does a plastic surgeon get involved in Moh’s resection of skin cancer? If the defect resulting from skin cancer excision is small or uncomplicated then the Moh’s surgeon might perform the closure. However many times the defect may be larger than expected, involve a critical structure, or be quite complex. Occasionally general anesthesia, a brief hospital stay, multiple surgeries might be required. This is where I, as the plastic surgeon, get involved with the patient.

The relationship between the Moh’s Team and the Plastic Surgery Team is critical. Getting the wound repaired expeditiously is better for the result and patient. In other areas of the country, outside Morgantown West Virginia, a patient may wait days or even weeks before the wound can be closed by a plastic surgeon. I try to see the patient as soon as possible and bend my schedule to get the wound closed in the best manner and shortest time frame for the patient.

I have worked extensively with Dr’s Hancox and Carlisle, Moh’s Surgeons at Mountain State Dermatology, for years. This symbiotic relationship allows patients to be seen before  the cancer removal near a critical structure. Meeting the patient prior to resection allows me to discuss surgical options, create the best individualized surgical plan, show the patient examples of their particular surgery and recovery process, and demonstrate potential results they might have following surgery.

In addition the relationship allows same day scheduling of resection and repair of the skin cancer. So the patient can have the resection of the skin cancer at the Moh’s office and then travel to the hospital for the complex repair under the comfort of anesthesia. A same day process affords the patient the best of both worlds in resection and repair. The combination of these services, at this high level, is not offered anywhere else in our region!

Please see a few of my publications and videos on skin cancer reconstruction following Moh’s Surgery.

Forehead Reconstruction A to T flap after Moh’s Surgery

Eyelid Reconstruction Paper after Moh’s Surgery

Limberg Flap Following Skin Caner Resection

Hughes Flap for near Total Lower Eyelid Loss after Moh’s

Bone flap for Lower Eyelid Loss after Moh’s

 

“The Life, Rapid, Style, Fast, Easy, Painless, No Risk”: Face Lift: My opinion.

Every week I get asked questions about the facelifts that are advertised on TV or I see unhappy patients that have experienced these lifts. There are a number of different trademark names that these TV commercials refer however they are all essentially the same simple skin lifts. Patients are often attracted by the lure of low price, glossy pictures, and prospects of a quick and painless recovery.

Having surgery by a trained professional in a certified environment can be very safe and rewarding for the patient. However surgery can also be quite dangerous if performed by a poorly trained doctor in the back office of a strip mall. A quality surgeon should educate you as a consumer and also weigh your risks and benefits very carefully before proceeding with any operation. Your safety should be the surgeon’s and staff’s #1 priority, not just signing you up and swiping your credit card.

You should meet with your surgeon a number of times instead of a non-medical salesperson. Make sure you research your doctor to verify they are a board certified surgeon What is a Board Certified Plastic Surgeon? who has completed a residency that educates them in facial surgery. (Plastic surgery and ENT) Finally be careful and trust your gut. If its too good to be true it likely is.

I have attempted to collect articles and videos which detail the side of the story not seen on the infomercials. I hope these links help you make an informed decision when it comes to your facial surgery.

Here is an excellent article in the New York Times on the LifeStyle Lift, QuickLift, and all the other lifts. New York Times: A Face From an Infomercial

  • “But three Lifestyle Lift patients and Dr. Mario S. Yco, a board-certified otolaryngologist who was an employee of the company for about a year, said that patients were urged to put down a deposit before they met with a surgeon. “The consultant sold the surgery,” said Dr. Yco, who practices in Encinitas, Calif. Often by the time he saw patients, the surgery was booked. “There were many patients I had to cancel,” he said, explaining that he didn’t deem them appropriate candidates.”
  • “Sharron Bryant, a manager for Lindt Chocolates in Dallas, who got a Lifestyle Lift in 2007, said she had a “high pressure” consultation and put down a deposit before meeting a surgeon. Ms. Bryant, then 59, paid $6,100 for a Lifestyle Lift and chin liposuction. She never needed pain medication during her weeklong recovery, she said. But she disliked the loose skin that remained on her jowls and neck. “I got nothing for the money,” she said. She later paid $8,200 for a traditional face-lift from a different surgeon.”
  • On Realself.com, a Web site where patients discuss cosmetic surgery, 37 percent of the 170 people who reviewed the Lifestyle Lift said the procedure was “worth it,” while 63 percent didn’t think so.

Did you know? These Skin Lift procedures can be performed by ER doctors, Family Doctors, and OBGYN’s. Make sure to investigate and validate the surgical training of your surgeon.

USA TODAY article reporting the frightening environment of cosmetic surgery in America. USA Today: Cosmetic Surgery Gets Cheaper, Faster, Scarier

  • “these new-style surgery clinics are under so much sales pressure they often don’t sufficiently screen patients for medical problems, do inadequate follow-up and persuade patients to undergo procedures that are either unnecessary or unlikely to get good results.”

Did you know? Many of the doctors that perform these type of facial surgeries would not be able to get hospital privileges (from the hospital board) to perform these procedures in a real operating room. They may not even be able to admit you to a hospital should you need acute care or emergent surgery.

Woman dies in Massachusetts during Lifestyle Lift   Woman dies during Lifestyle Lift

Lifestyle lift under investigation for unethical (high pressure) sales practices. Former doctor claims was a “mill” and patients “mislead”, “Some procedures were inappropriate”. Florida Attorney General Investigates Lifestyle Lift

New York Attorney General in 2009 found the LifeStyle lift was intentionally and illegally “duping” consumers. New York Times “Company Settles Case of Reviews It Faked”

  • Andrew M. Cuomo, New York’s attorney general, said in a statement that Lifestyle Lift’s “attempt to generate business by duping consumers was cynical, manipulative and illegal.”

 

LifeStyle Lift Exposed during 3 month investigation on CBS.

CBS Part 1: Lifestyle Lift Exposed

  • “Met doctor 15 min before surgery” “Lack of Results” “Poor followup” “Stitches left in a month”

CBS Part 2: Lifestyle Lift Exposed

CBS Part 3: Lifestyle Lift Exposed

  • Chief of Facial Plastic Surgery at Emory Comments on Lifestyle Lift: “What they do offers nothing new, unique or different”. “Technique has been around since the 1960’s”. “I don’t think speed should be a selling tool.” “You get what you pay for”.

CBS Part 4: Lifestyle Lift Exposed

  • Notice the scar is in front of the tragus (little protrusing in front) of the ear. Also that the earlobe is pulled downward (Called Pixie Ear). These are classic examples of old technique, lack of attention to detail, and of not taking the time to hide the scar as well as possible and prevent pulling on the earlobe.

CBS Part 5: Lifestyle Lift Exposed

  • “Met her doctor the day of surgery” “LifeStyle Lift quick to sue to hide their critics” Patient states, “Not warned about scars or risks prior to surgery”

CBS Part 6: Lifestyle Lift Exposed

  • Lifestyle lift sues the TV station and the Reporter performing the investigation. Reporter: Lifestyle Lift “fast paced money driven environment”. Lifestyle lift has sued WebMD, RealSelf, and Infomercial scams. All suits were thrown out or dropped.

CBS Part 7: Lifestyle Lift Exposed

  • “Lifestyle lift not something of Hope but of Horror” “I think it was very deceiving” “Told me I could go back to work the same day after the facelift (paraphrased)” “No Followup” “no instructions” “I would not go back and have it done again” Numerous employees told to close the deal “no matter what” Holy Cow check out the post op photo’s!

CBS Part 8: Lifestyle Lift Exposed

  • “Corporate culture that places a priority on sales, often at the expense of the patient”. Former employee, “It was terrible”. The founder is a Doctor of Osteopathy who formerly did in Hair Replacement. Employee: “keep patients in dark” “no education for aftercare” “many unsatisfied customers”. Former employee: “Doctors must perform a certain number of surgeries per day” “15 new patients weekly at a 50% closure rate anything less does not meet company expectations”. “Signing people up for surgery even though you couldn’t give them what they wanted.” “A doctor would leave in the middle of surgery to go see a consult that couldn’t wait” “It shocked me because in a hospital I had never seen a doctor leave a patient while their incision was open.”
  • “Employees questioned the cleanliness and safety of the operating room with urine on the table and floor”.

Video Atlanta Lifestyle Lift (In the Procedure Room)  So whats really important in this video from a medical standpoint?

  • First of all, this procedure is in the office not an operating room.
  • There is no anesthesiologist present to protect the airway or monitor the heart. Actually there is no monitor at all, although the patient get oral medication as well as an injected medication.
  • Notice the doctor and assistant. No gown, hair net, no drapes on the patients body.
  • The incision is placed in front of the ear = old technique that is faster to perform and sew up but not hidden.
  • The patients earlobe is sewn to her facial skin flap (Classic old technique sign of facelift) = in 6 months she will likely have pixie ear. What is Pixie Ear after Facelift?

Some QUESTIONS you may want to ask a doctor who intents on performing facial surgery in order to stay safe.

  • Do you have surgical privileges at a local hospital?
  • Where will the surgery it take place? Office or Operating room?
  • Is the facility certified?
  • Cardiac monitor? Oxygen Monitor?
  • Anesthesiologist present?
  • How do you protect my airway (breathing)?
  • Do I get antibiotics before the surgery?
  • When do the stitches come out?
  • What is the follow-up?
  • What kind of complications have you had?
  • Will I have drains?
  • Who do I call with problems?
  • Do you have a protocol in place should I have a problem during surgery?
  • Are you a Board Certified Plastic Surgeon?
  • Is your Board Certification recognized by the American Board of Medical Specialties?

 

Why is Board Certification in Plastic Surgery important for you?

Caveat Emptor = Latin for, “Let the buyer beware”.

Unfortunately cosmetic surgery is essentially the wild west, Plastic Surgery: The Wild West of Medicine , with very few if any restrictions or oversight as to who may operate on you. Many patients are surprised to learn that any medical doctor, regardless of training, can legally perform “plastic surgery” and call her or himself a “plastic surgeon”. Although their name may be listed under Plastic and Reconstructive Surgery in the Yellow Pages they may not have completed ANY training in the speciality!  

These physicians essentially misinform you by stating they are “board certified”. However they don’t highlight in what field they are Board Certified (Family Practice, ER, ObGYN).  Doctors may claim to be certified by the “American Board of Cosmetic Surgery” (Not recognized by the American Board of Medical Specialities as a “credible” certification because the training of its members is not supervised, credentialed or possibly even valid) Recently the California Board of Medicine voted unanimously voted to deny recognition of the American Board of Cosmetic Surgery. California Medical Board Votes Down ABCS

In this geographic area there are Ear Nose and Throat doctors performing breast augmentation,  ER doctor performing facelifts, and ObGYN performing liposuction. These doctors often perform procedures in their offices because a credential committee (group that validates training) of a hospital would not permit them to perform these services in an Operating Room due to of lack of training. Furthermore if you were to have a complication requiring admission to the hospital these doctors may not even be able to admit you as they may not even have ANY hospital admitting privileges.

Just because your surgeon is on TV doesnt make him/her any good either. Many of the Plastic Surgeons you see on Dr. 90210, Discovery, Swan etc. are not board certified. See this video from the USA Today on how the lack of training can be deadly: USA Today Article on Plastic Surgery

So how can you protect yourself? Start with understanding credentials. Make sure your Plastic Surgeon is certified by the American Board of Plastic Surgery. This Board is  recognized by the American Board of Medical Specialties, the governing board of all physician training in the US. ABMS Website “What is Board Certification”   It requires minimum 6 years of surgical training, 3 years in Plastic Surgery specifically. There is a rigorous Written and Oral Board examination on cosmetic and reconstructive surgery where experts examine the surgeons own patients outcomes. The failure rate of the oral board examination is 23%! Imagine that, after 6-8 years of training and minimum 1 year of active practice, and passing a rigorous written examination, about 23% of surgeons fail to pass the certification exam. A few never pass. (No wonder these other doctors take the easy way out and just call themselves Plastic Surgeons!)

Additionally Board Certified Plastic Surgeons are required to operate in only accredited facilities, required to perform continuing education, adhere to a strict code of ethics, and are highly trained in all aspects of Plastic Surgery.

So if you go to a Board Certified Plastic Surgeon are you going to get good results? Not always. You need to go one step past Board Certification. Ask lots of questions, look at before and after photos, call their previous patients, and go with your “gut”. As Malcolm Gladwell proposed in Blink: The Power of Thinking Without ThinkingGladwell Summary ,  you’ll know in the first minute whether or not this is the right doctor for you based on your adaptive unconscious.

Good luck, be smart, and be safe.

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