Papers of Dr. Kenneth Benjamin Hughes, MD
Telemedicine: Risks, Benefits, and Pitfalls in the Postoperative Care of Plastic Surgery Patients and Review of the Literature
As a practice grows in volume and reputation, a plastic surgeon may be asked to perform surgical procedures on patients from neighboring states, other areas of the country, and even other countries. Dr. Kenneth Benjamin Hughes has seen patients from dozens of countries and 6 continents. Postoperative follow-up in these situations is anything but routine, and, until recently, these patients of medical tourism had no direct way to follow-up with their surgeons without both great expense and time expenditure. Digital image transmission has been studied in the plastic surgery literature as a means to evaluate wounds, skin malignancies, digital injuries, and free flap viability (whether transferred tissue lives or dies).
However, there remains little information regarding the use of patient-submitted digital images and their role in preoperative evaluation and post-operative follow-up in the plastic surgery patient. With the advent of digital imaging and, more specifically, the global, mass-market spread of high resolution, automatic point-and-shoot cameras and more recently smart phones, Dr. Kenneth Hughes and the other authors sought to evaluate the utility of patient-taken digital photographs as a means of follow-up after plastic surgery procedures.
This study reviewed 25 patients in two surgeons’ practices over a 3 year period, focusing specifically on those patients who were unable to return for follow-up and experienced a complication or a concern about healing. Detailed instructions were given to patients to facilitate acquiring standardized views of the surgical area. The images were transmitted to the surgeon for review by email.
All 25 patients were able to take accurate digital photographs with standard views of the areas involved. Follow-up ranged from 2 months to 3 years, with an average follow-up of 4 months. The most common postoperative complications were incision breakdown or dehiscence (6), breast cellulitis (5), and breast bruising, without hematoma (2). The largest subgroup (10) included normally healing wounds in the postoperative patient.
These patient-submitted images proved invaluable in determining the need for additional intervention, while initial trepidation about poor image quality proved unfounded. In fact, with improved camera systems on smart phones both with the ease of use and in image quality, the process is actually facilitated well. The authors offer this postoperative management paradigm as a novel way to meet an ever expanding, ever more diverse patient population who scours the globe for plastic surgical expertise.
Prior to the development of technology within the last several years, patients from remote geographical locales could not follow-up with their plastic surgeon without great commitment of time and expense; routine follow-up was difficult in most cases. Using telemedicine to follow the postoperative course of this subset of plastic surgical patients provides a solution. PubMed searches performed for “telemedicine and plastic” revealed a total of 44 publications of which the more relevant will be reviewed in the following paragraphs. One should note that the majority of these studies involve trained, hospital affiliated personnel with proper camera equipment and not patients using cellular phone cameras.
A review of the literature of reveals that the majority of publications on the topic of telemedicine in plastic surgery has taken place over the last eight years, yet we as a group are far from taking advantage of the full array of its benefits. Pap et al. reviewed a a multi-institutional study utilizing plastic surgery residents taking digital images of radiographs and complex wounds of the hand and face following trauma and transmit them electronically to the attending physicians on call. The authors evaluated 20 patients, 12 of whom had hand injuries. This method of review proved reliable for triaging and discerning additional operative management. 1 Study limitations were defined by the current technology: picture resolution of the two megapixel camera as well as the storage size of the file (picture size of 400 × 320 pixels, 100 dots per inch) and electronic transmission speed available at that time. The study highlighted patient privacy and the need for encryption – 128-bit encryption was employed in this study. 1
Jones et al. in 2004 published an extensive study of 150 images after trauma and burns that were taken by trained personnel in the emergency room setting. They also involved an IT staff to develop software to enable faster transmission, encryption, and storage. Even with these advantages, they had to compress the images to 800 x 600 pixels in JPEG format. Additionally, only 82 of the 150 images were able to be evaluated due to data gathering loss or inadequate image capture. They cited recurrent technical difficulties and significant capital outlay was significant. 2
A case report published in 2004 demonstrated an early account of the use of images taken by a patient’s cellular phone to document a finger wound over an eight day period. 3 The authors pointed out the low cost and easy manipulation with such a technique. 3 However, resolution was limited with technology of cellular phone cameras at this time.3
The first large study utilizing a mobile camera phone was published later in 2004 by Hsieh et al. 45 patients with 81 digital injuries were evaluated by 110,000 pixel digital camera images taken by surgical residents in the emergency room. These camera phone images were transferred to another camera phone as 132 × 176 JPEG files to be viewed by the consulting surgeon. In 25 percent of the cases, there was significant discordance in triaging. Camera phones at this time were not capable of generating high-quality images suitable for surgical interpretation in a reliable fashion. Also, 3G and 4G networks did not exist and significantly compromised the image transmission quality. 4
Tsai et al. evaluated extremity wounds in 60 patients with camera phones of residents and transmitted images to consulting surgeons. In this study, surgeons had similar difficulty triaging due to image quality, reporting 68% to 90% concordance among surgeon evaluators. 5
Another study published a few months later evaluated potential for replantation in amputated fingers. This study utilized images from camera phones taken by emergency room personnel that were transmitted to consulting plastic surgeons. 35 patients with a total of 60 digital injures were evaluated in this manner, and the sensitivity and specificity of recognizing digital replantation potential was determined to be 90% and 83%, respectively. 6
Wright, et al. evaluated 151 cases after preoperative image procurement and showed that 68.9 percent of those patients in this see-and-treat protocol for plastic surgery were not able to be treated that same day. The authors cautioned that patient and surgeon alike must be prepared for cancellation on the day of surgery if cases are incorrectly designated. 7
Murphy, et al. compared the evaluation of wounds of by a vascular surgeon, a surgical resident, and later by a plastic surgeon. This study utilized a 3.3 megapixel camera and agreement among study personnel was largely uniform. 8
Wilkins, et al. completed a nine month pilot study to evaluate largely lower extremity chronic wounds in 56 patients by remote means. Surveys showed 98.2% patient satisfaction and similar satisfaction on the part of the referring physician. This study was one of the first to focus on the satisfaction of patient and physician alike with the telemedicine consult system. 9
Diver, et al. studied twenty patients in triage setting before transferring traumas for plastic surgical evaluation. Management was only altered in one instance after the consultation by the plastic surgeon. They alluded to the reduced costs with such a system in place. 12
Tadros, et al. examined a series of 300 patients after digital image capture for skin malignancy and other cutaneous lesions. They reported diagnostic accuracy in a random sample of 30 patients to be comparable to face to face consultations. 13
However, there is no question that store-and-forward technology and televideo have been underutilized and underdeveloped. 14 Knobloch, et al. theorized that a cell phone-based multimedia service allows for transmission of high-resolution photographs and short videos that would be useful in free flap surveillance. 15
What should be demonstrated at this juncture in the evolution of telemedicine is whether or not patient taken images can be useful in preoperative diagnosis, postoperative diagnosis, or surveillance. A six month study evaluating patient taken images has gotten underway at George Washington University. They have been evaluating emergency room patients with wounds, infections, and rashes. The preliminary results of the study look promising, with a reported 90% accuracy. 16
In this same manner, the goal of this study is to follow the postoperative course of plastic surgical patients with patient-taken images and determine the feasibility of this method as a postoperative management paradigm for those patients who are separated from their surgeons by issues of geography.
After being granted Institutional Review Board approval at Beth Israel Deaconess Medical Center, information was collected from the charts of 25 patients who took digital photographs of their operative sites during their postoperative course. Follow-up ranged from 2 months to 3 years, with an average follow-up of 4 months. The most common postoperative complications were incision breakdown or dehiscence (6), breast cellulitis (5), and breast bruising, without hematoma (2). The largest subgroup (10) included normally healing wounds in the postoperative patient.
Table 1 shows the entire list of patients involved. Neither specific ages nor specific locations of individual patients are presented to maintain patient confidentiality. However, to give an idea of the geographical span, these patients were separated by as little as a state ( New York) to overseas ( France).
1) normal healing following secondary breast augmentation
2) dehiscence of donor site after latissimus flaps with implants for breast reconstruction
3) normal healing following eyelid lesion removal
4) erythema after symmastia repair with Strattice
5-8) wound breakdown of breast following breast reduction (3), DIEP (1)
9) dehiscence after thigh lift
10-14) breast cellulitis after breast reduction (2), DIEP (1), tissue expander placement (2)
15-16) bruising after breast reductions (2)
17) seroma after abdominoplasty
18-19) normal healing after skin grafting
20) normal healing after DIEP flap
21) normal healing of subciliary incision after facial fracture repair
22) residual swelling after lower bleph
23) partial thickness burn after breast reconstruction
24) normal healing after medial canthal basal cell carcinoma removal
25) normal healing after latissimus flap with implant for breast reconstruction
Review of Select Cases
The first case was a young female who presented after primary breast augmentation with a double bubble deformity. She had a periareolar revision with correction of the deformity. She took standardized views of the breast postoperatively, which are provided in Figure 1, and had an uneventful postoperative course.
The second case was an elderly lady who presented to clinic with bilateral breast implant rupture. She had undergone implant-based breast reconstruction 20 years prior to presentation. She underwent breast revision surgery with placement of new implants. She had concerns about her left breast postoperatively, but subsequent image procurement allowed the surgeon to reassure the patient (see Figure 2).
The third case is a middle-aged old female who underwent breast reduction surgery. She developed an area of wound breakdown, which was managed conservatively (see Figure 3). The area healed without additional problems.
The fourth patient underwent skin-sparing simple mastectomy and immediate DIEP flap reconstruction. Two of her postoperative images are presented in Figure 4.
The fifth patient was a young male who underwent open reduction and internal fixation of a right orbital floor fracture with titanium mesh plate. Postoperatively, the patient became concerned about the reddened nature of his subciliary incision after about 1 week (see Figure 5). Pt had a full return to function without visual disturbance, enophthalmos, or lid malposition.
The sixth patient was a delayed breast reconstruction s/p mastectomy and radiation who was reconstructed with a latissimus flap and implant after repeated failures with implant-based reconstruction alone at an outside institution. She expressed concern that her flap had changed colors over the course of the week (Figure 6). There was no cause for concern, and she has healed uneventfully.
Escalating Technology and Patient Instruction
While very little has been published in regard to amateur procurement of images in plastic surgery, the global availability of affordable, user-friendly, wireless internet capable cellular phones with higher resolution point-and-shoot cameras allow an individual to create high quality images with little instruction. Most of these cameras have built in automatic zoom lenses and a series of automatic settings, which adjust light capture and promote better image quality. The technical aspects of creating a high quality image have been increasingly simplified.
Virtually any make or model of cellular phone made after 2008 contains at least a 2 or 3 megapixel camera and 8 megapixel cameras are commonplace on phones of today. From a resolution of image standpoint, patient taken photographs are already more than adequate and they will only get better with each passing year.
What compromises photo quality more from the surgeon’s perspective is the inability to create standardized or useful images by the patient photographer. However, with a few instructions to the patient, reasonable views can be obtained. Most frequently, we ask patients to get two lateral views and an AP view, although other views are sometimes obtained We also emphasize that the distance from the subject is kept constant and that the height of the camera is kept constant as well. This study along with several others in development is demonstrating the efficacy of patient taken photographs in managing patient expectations and outcomes.
For managing patients who cannot follow-up with their plastic surgeons due to geographic constraints or undue expense, telemedicine provides an avenue of follow-up, which did not exist just a few years ago. Unlike previously published studies, which involved trained photographers, this study only evaluated patient-taken images. The image quality and the perspectives obtained proved adequate for interpretation. Ultimately, these images helped usher in a new postoperative management paradigm to the practices studied, and we offer this as a useful adjunct to any practice that delivers healthcare to patients from diverse locales.
Since this article was written in 2011, the last 8 years have ushered in forever more sophisticated technology with greater image quality and easier photo taking mechanisms. A cell phone image can produce such compelling photos that the evaluation of patients has been markedly improved. Dr. Kenneth Hughes welcomes the improved technology and integrates these improvements to help his patients.
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Insights into the Management of Keloid Scars: A Survey-Based Protocol
Dr. Kenneth Benjamin Hughes, Los Angeles Plastic Surgeon
In the broad array of literature as it relates to keloid treatment, there is a global absence of definitive protocols in the management of keloid scars.
The goal of this project was to find some common ground in treatment regimens among plastic surgeons and to determine how our treatment protocol compares with those of other plastic surgeons. To this end, a web-based survey was designed and over 700 random emails were sent to plastic surgeons worldwide, with 54 completing the survey. These results were then tabulated and the more common regimens identified.
The results of the survey, while useful in identifying common regimens and helping to substantiate the validity of our protocol, underscore the need for randomized, controlled trials to bring about more consistency in regimens used.
Keloids arise as an aberrant tissue response to cutaneous insult characterized by the production of excessive fibrous tissue. Keloids extend beyond the original boundaries of tissue injury and may appear months to years after injury. They occur with equal frequency in males and females and occur most commonly in younger people.
Keloids have a predilection for the earlobes, chest, back, neck, and shoulders. Keloids tend to afflict those people that are more pigmented, with blacks being the most susceptible. Keloids may be symptomatic; commonly causing itching, tenderness, and pain. The etiology of keloids is unknown. Some have demonstrated that increased extracellular matrix production is characteristic. 1-4 Keloids remain difficult to treat under even the most optimal of conditions, and they frequently recur.
An array of adjunctive therapies including silicone gel sheeting, pressure garments, intralesional steroids, and radiotherapy have been employed with variable success.
Several randomized, controlled trials have confirmed the validity and effectiveness of silicone sheeting. 5-11 Though effective, the silicone material be worn continuously for months at a time to prevent rebound hypertrophy. 12
Pressure therapy involves the exertion of at least 24 mmHg to exceed the inherent capillary pressure. 13,14 Much like silicone materials, pressure garments should be worn 18 to 24 hours a day for several months. 15-18 Surgery in conjunction with pressure therapy has produced success rates of up to 90 percent. 19-23
Steroids have been demonstrated to soften the contours and reduce the bulk of keloids. 24-28 Response rates vary from 50 to 100 percent, with recurrence rates of up to 50 to 80 percent. 24-28 Steroids purportedly decrease collagen synthesis by increasing metalloproteinase activity. 29-34 The optimal number of injections to be performed and the amounts injected to produce an optimal response are largely up for speculation.
Radiotherapy has been employed as both adjunctive and primary treatment. Radiation therapy is presumed to destroy and kill the proliferating fibroblasts, resulting in diminished collagen production. 35 Radiation treatments are typically administered over five to six sessions in the early postoperative period to cause cell death. 36, 37 The combination of surgery and perioperative radiation therapy reduces recurrence to 10 percent according to some authors. 35 Historically, radiation therapy has been reserved for abnormal scars resistant to other treatments due to the presumed risks posed by radiation.
Excision and Intralesional Steroids
Though all of the modalities presented thus far have roles to play in keloid management, local excision in combination with intralesional kenalog has long been the definitive treatment for keloids. However, there is lack of a standardized protocol (including specific steroid, strength, number, and frequency of doses to be administered) in the published literature. 38
To undertake this task of searching for a treatment protocol, a random compilation of board certified plastic surgeons was made comprising over 700 names. Next all of these selectees were emailed a letter asking for participation in filling out a web-based survey. Ultimately, 54 respondents filled out the survey. Participants were queried on steroid preference, concentration and volume injected, number of treatments, frequencies, and the temporal relationship of those injections to excision. Finally, those surveyed were asked to provide additional therapies they found useful in treating keloids.
The results were then tabulated and expressed as percentages. Only the most common responses have been tabulated.
Kenalog 40 mg/ml
Q month x 3 50%
Q 6 weeks x 3 25%
Q month x 3 39%
Q 6 weeks x 3 32%
Postoperative Adjunctive Management
22% as primary form of treatment after excision
46% for refractory keloids
Silicone Gel Sheeting - 26%
Compression Garments - 22%
Cordran tape - 17%
Table 1 illustrates that Triamcinolone (kenalog ® )appears to be the overwhelming favorite for steroid injection. Although the majority of the respondents used 40 mg ml concentrations, many of these were diluted 2 to 1. After accounting for dilution, relatively equal numbers used each of the concentrations of kenalog.
Table 2 reveals that all of the plastic surgeons surveyed practice excision, which is what one expects when referred to a surgeon for treatment of a keloid. One also notices that the majority of surgeons injected 1ml and that the majority administer perioperative steroids. As far as dosing intervals go, q month dosing for a total of 3 treatments was the most common preop and post op regimen, with q6 week dosing for 3 doses being the second most common.
While excision and intralesional kenalog® constitute the most common treatment algorithm, it was interesting to note that (see Table 3) 22% used radiation as a primary form of treatment following excision, and that almost ½ used radiation at some point in their treatment algorithm. Silicone gel sheeting (26%), compression garments (22%), and cordran tape (17%) constituted the majority of the other adjunctive therapies.
Therefore, if one were trying to define the most common algorithm, it would consist of the following:
1) Excise the keloid, injecting 1 ml of 10, 20, or 40 mg/dl kenalog at the time of surgery
2) Inject 1 ml of 10, 20, or 40 mg/dl kenalog into the keloid postoperatively every month for a total of 3 doses
These findings are largely supportive of and consistent with the protocol presented by the authors:
1 cc of Triamcinolone 10mg/ml (kenalog 10®) is injected in the lesion (in smaller lesions fluid is injected until blanching is obtained). After a waiting period of 2-3 weeks, a full excision of the lesion is performed, while achieving good hemostasis and utilizing non-absorbable suture material for closure. At postoperative day 7, the suture material is removed and 1 cc of kenalog® 10 injected into the surgical scar. This is followed by 2 more injections of the steroid every 4 weeks.
Excision after 2 weeks
Injection #2 at 1 week post op
Injection #3 at 4 weeks
Injection #4 at 8 weeks
Hopefully, the findings articulated in this paper will be useful to plastic surgeons managing keloid scars, particularly those physicians just beginning a practice and physicians in training. The paper also highlights the overwhelming need for prospective randomized trials to examine such protocols and their validity in the management of keloids. However, the results obtained within this paper do shed light upon the current thinking and management tactics of practicing plastic surgeons worldwide.
Plastic Surgery Task Force Recommendations to Avoid Fat Emboli and Death in Brazilian buttlift
It advised doctors to:
Stay as far away from the gluteal veins and sciatic nerve as possible. Fat should only be grafted into the superficial planes, with the subcutaneous space considered safest. If the aesthetic goal requires more fat than can be placed in the subcutaneous layer the surgeon should consider staging the procedure rather than injecting deep
Concentrate on the position of the cannula tip throughout every stroke to assure there is no unintended deeper pass, particularly in the medial half of the buttock overlying the critical structures
Use access incisions that best allow a superficial trajectory for each part of the buttock; avoid deep angulation of the cannula; and palpate externally with the non-dominant hand to assure the cannula tip remains superficial
Use instrumentation that offers control of the cannula; avoid bendable cannulas and mobile luer connections. Vibrating injection cannulas may provide additional tactile feedback
Injection should only be done while the cannula is in motion in order to avoid high pressure bolus injections
The risk of death should be discussed with every prospective Brazilian butt lift patients
Dr. Hughes designed these maneuvers over 3 years ago to help minimize the risk of fat emboli and death. Dr. Hughes has performed 1500 BBLs since that time without a death from fat embolus or fat embolus of any kind. It is important to realize that even if fat emboli are not fatal they can produce many other complications due to the inability of the lungs to deliver the oxygen the body needs to critical organs like the brain and kidneys and heart.
Dr. Kenneth Benjamin Hughes and The Removal of Dead Fat (Fat Necrosis)
Few people know what fat necrosis is, how it occurs, or why it is important. Fat necrosis is dead fat that occurs usually secondary to the lack of blood supply. Without the blood supply, the fat dies and becomes calcified and hard. This necrotic fat then may be painful or create an unpleasing appearance. Fat necrosis typically occurs as a result of trauma or secondary to transfer of fat during a surgical procedure.
Most commonly, Dr. Kenneth Benjamin Hughes sees this dead fat phenomenon secondary to Brazilian buttlift procedures or BBL procedures. Dr. Hughes specializes in revision surgery and in this particular surgery as well. The fat necrosis may need to be removed if it persists over a period of months or is extremely painful. Sometimes the dead fat can create dents, and sometimes it can create a large unsightly lump.
Dead fat, unlike living fat, cannot be removed by liposuction, or removal of fat through a cannula by pressure extraction. The dead fat hardened by calcium must be removed in total through an incision in the skin, much like a cyst or a tumor is removed.
If the removal is extensive, reconstruction with additional fat grafting may be necessary as well. Thus, the issue of fat necrosis requires an expert skill set to create the optimal result.