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The article by Furuya et al. focuses on surgical site infections (SSIs) after liposuction in the Dominican Republic. The outbreak is likely due to inadequately sterilized liposuction cannulae.

The issue seems to affect a wide variety of cosmetic surgery procedures in countries like Venezuela and the Dominican Republic. It gives rise to the question: is plastic surgery in Venezuela safe ? Breast reductions, breast augmentations tummy tuck, injections into various body sites, face lifts are affected. A CDC report published in MMWR 47(49):1065-7 detected infections with rapidly growing mycobacteria (RGM) in patients from eight different hospitals in Caracas, Venezuela, which cleaned surgical instruments with tap water followed by low level desinfection with a commercial quarternary ammonium solution. These sterilization practices compare very unfavorably with US or European standards in widespread use in the English speaking Caribbean such as use of 2% glutaraldehyde solution followed by steam sterilization in class N autoclaves, possibly with pulse vacuum cycles or similar. It also outlines some of the risks unsuspecting patients face when undergoing cosmetic surgery and plastic surgery in Venezuela and the Dominican Republic, which seem to be particularly deficient in these standards, as the majority of outbreak and case reports in the literature of SSIs with RGMs are linked to those two countries. Are they improving ? Maybe, at least the outbreak reports have given way to the case reports. Is plastic surgery in Venezuela safe now ? Also only a maybe – once they work with sterile instruments !

Another CDC report (MMR 53(23):509) seems to report part of the same outbreak with Mycobacterium abscessus (a RGM) as Furuya et al., albeit the surgical spectrum is different. Breast augmentation, breast reduction, breast lift, abdominoplasty and liposuction are listed as index procedures. Interestingly, nothing specific is reported about the one case of breast augmentation. So it is unknown if implants had to be removed or repeat augmentation was performed once the infection had cleared under prolonged antibiotic treatment. Neither do any of the reports provide data about the total cost of treatment.

So the necessity of using sufficiently advanced sterilization practices must really be emphasized. No corners can be cut here. While not of equal magnitude as the PIP breast implant (Polyimplante Prosthesis breast implants) scandal in Venezuela and Colombia (about 30000 and 14000 recalled implants still in situ), avoidable complications due to inadequate sterilization of surgical instruments and liposuction cannulae the cited outbreaks should caution surgical facilities to implement stringent sterilization and infection control practices. So is plastic surgery in Venezuela safe ? Well, make sure you see them clean and put the instruments in a high end autoclave and have a look at the implants they want to put in before you go.

 

 

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Acne, Acne Scars and Skin Treatmtents

The articles by Taylor and Dunwell et al. both give evidence of a high prevalence of acne in the Caribbean. They give less information about the severity of acne and acne scars. Both represent a formidable cosmetic problem in light skin, e. g. Fitzpatrick III or less. The classic treatment options for acne scars are outlined in most dermatology or plastic surgery texts – chemical peeling, laser resurfacing and dermabrasion.

In dark skin types especially Fitzpatrick V and VI effective laser resurfacing with a “hot” (CO2) laser is not really an option due to the considerable risk of permanent pigment changes and the increased risk of unfavorable scarring. Medium depth chemical peels are however moderately useful for acne scars and can be used in darker skin types. Dermabrasion may be the most applicable option. An innovative method, called sandabrasion, uses medical grade sanding paper to manually plane the the skin surface, instead of a mechanical diamond brush dermabrader. Some more innovative methods are listed on the Trinidad Institute of Plastic Surgery website, which has accumulated considerable experience with the problem of acne scars on dark skin.

Even more than in light skin types prevention of acne scars is of paramount importance in dark skin in the Caribbean. Prevention of acne scars, which are more often than not only incompletely treatable, is thus of paramount importance. Prevention of acne scars means aggressive medical treatment by a qualified practitioner like a board certified dermatologist or plastic surgeon.  Both are far and in between in the Caribbean. Thus unfortunately acne is often treated by unqualified personnel not cognizant of the disease and its potential lifelong consequences.

The principles of medical treatment to prevent acne scars are lifestyle modifications, hormonal balancing and topical and systemic anti acne medications. Significant commitment to treatment is necessary as well as of financial resources over several years. These commitment are however a small price to pay to avoid lifelong disfigurement in the face and considerably more expensive treatments later for acne scars.

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Epidemiology of skin diseases in ethnic populations.

Skin of Color Center, St Luke’s-Roosevelt Hospital Center, 1090 Amsterdam Avenue, Suite 1l-D, New York, NY 10025, USA. drstaylor1@aol.com

The spectrum of cutaneous disease occurring in ethnic populations as well as Caribbean skin treatment are as broad and diverse as the ethnic populations themselves. Many skin diseases are seemingly common to most of the ethnic populations, however, including blacks, Hispanics, Asians, and Native Americans. These diseases include acne vulgaris; pigmentary disorders; eczematous dermatitis; and infection caused by bacteria, fungi, and viruses. Diseases of a more cosmetic nature have emerged over recent years and include the pigmentary disorders melasma and postinflammatory pigmentation, acne keloidalis nuchae, scalp and facial folliculitis, keloidal scarring, alopecia, and photoaging, all playing an important role in the Caribbean skin treatment spectrum. The identification of cutaneous diseases affecting the rapidly increasing ethnic populations serves to focus resources both research and clinical in these areas.

Study of the skin disease spectrum occurring in an Afro-Caribbean population.

Musgrave Medical Centre, Kingston, Jamaica.

BACKGROUND:

There is a scarcity of recent up-to-date studies on the incidence of skin disease among Afro-Caribbeans and the modalities of Caribbean skin treatments.

METHODS:

One thousand patients were retrospectively studied for the most common diagnoses made over a 5-month period from January to May 2001.

RESULTS:

The commonest skin diseases seen were acne vulgaris (29.21%), seborrhoeic eczema (22.02%), pigmentary disorders (16.56%), and atopic eczema (6.1%). Other notable common diagnoses included keratosis pilaris, tinea infection, hirsuitism, folliculitis keloidalis nuchae, viral warts, dermatosis papulosa nigra, and confluent and reticulate papillomatosis, which also largely determine the Caribbean skin treatment spectrum.

CONCLUSION:

The patterns of skin disease seen and Caribbean skin treatments provided in the Afro-Caribbean population studied, more closely resembles those seen in developed countries than those seen in developing countries.

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Outbreak of Mycobacterium abscessus wound infections among “lipotourists” from the United States who underwent abdominoplasty in the Dominican Republic.

Clin Infect Dis. 2008 Apr 15;46(8):1181-8.

Furuya EY, Paez A, Srinivasan A, Cooksey R, Augenbraun M, Baron M, Brudney K, Della-Latta P, Estivariz C, Fischer S, Flood M, Kellner P, Roman C, Yakrus M, Weiss D, Granowitz EV.

Department of Medicine, New York-Presbyterian Hospital-Columbia University Medical Center, New York, New York, USA.

BACKGROUND:

Some US residents travel abroad to undergo cosmetic plastic surgery Dominican Republic for fat removal, a practice referred to as “lipotourism.” Mycobacterium abscessus can cause postsurgical wound infection.

METHODS:

US residents who developed M. abscessus wound infection after undergoing cosmetic surgery in the Dominican Republic in 2003 and 2004 were identified using the Emerging Infections Network listserv.

RESULTS:

Twenty returning US travelers with M. abscessus infection were detected after plastic surgery Dominican Republic. Eight patients had matching isolates, as determined by pulsed-field gel electrophoresis and repetitive element polymerase chain reaction. All 8 patients, who had previously been healthy Hispanic women, underwent abdominoplasties at the same clinic in the Dominican Republic. Symptoms first developed 2-18 weeks after the procedure (median interval, 7 weeks). Only 2 of the 8 patients received a correct diagnosis at the initial presentation. Most patients presented with painful, erythematous, draining subcutaneous abdominal nodules. Seven patients underwent drainage procedures. Six patients received a combination of antibiotics that included a macrolide plus cefoxitin, imipenem, amikacin, and/or linezolid; 2 received clarithromycin monotherapy. All patients but 1 were cured after a median of 9 months of therapy (range, 2-12 months). Because of a lack of access to the surgical clinic, the cause of the outbreak of infection was not identified. The patients who were infected with nonmatching isolates underwent surgeries in different facilities for plastic surgery Dominican Republic but otherwise had demographic characteristics and clinical presentations similar to those of the 8 patients infected with matching isolates.

CONCLUSIONS:

This case series of M. abscessus infection in US “lipotourists” highlights the risks of traveling abroad for surgery and the potential role of the Internet in identifying and investigating outbreaks.

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Ethnic and cultural variations of preferences regarding breast size and body shape play an important role in body contouring, body sculpting and breast shaping.  The recent article by Gray et al. in Evolutionary Psychology adds some corroborating data to the existing body of knowledge.

Plastic surgeons with an active practice in body contouring have long known about the importance to vary surgical objectives depending on the ethnicity of the patient. This is particularly applicable to gluteal sculpting aka Brazilian butt lift in the Caribbean and breast augmentation. We have yet to find an ethnic group which prefers more  rather than less fat on the belly. Breast reduction is performed to alleviate symptoms arising from large breasts, so here the desire of the patient is fairly uniform across ethnicities – the breasts should be rather smaller than larger. Now with respect to buttock reshaping with the Brazilian butt lift or buttock implants the differences are striking – in the Caribbean we find an almost uniform preference for wide, full and projecting buttocks very different to the often rounder and athletic ideal in a predominantly Caucasian population. With regards to volume alone, which is secondary to shape in terms of importance, according to clinical experience the difference is about twenty to forty percent.

Of particular interest is the conclusion in the article that men as well as women favor smaller breast sizes. This needs to be viewed in the light of clinical experience. Breast augmentation is sought by women with small  breasts in the Caribbean at the same frequency as in a predominantly caucasian population similar to the control groups in the article. The most noticeable difference is the preference for smaller implants in the Caribbean. The vast majority of women request a breast size which would not give away the presence of implants to the curious but casual observer, e. g. a casual acquaintance they meet while in street or business clothes. Thus, while the desireable volume of buttocks achieved with the Brazilian butt lift or gluteal implants in the Caribbean is an average forty percent large, the volume of breast implants used is about thirty percent smaller.

So butt before breasts in the Caribbean ?

 

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Department of Anthropology, University of Nevada, Las Vegas, USA.

We investigated body image in St. Kitts, a Caribbean island where tourism, international media, and relatively high levels of body fat are common. Participants were men and women recruited from St. Kitts (n = 39) and, for comparison, U.S. samples from universities (n = 618) and the Internet (n = 438). Participants were shown computer generated images varying in apparent body fat level and muscularity or breast size and they indicated their body type preferences and attitudes. Overall, there were only modest differences in body type preferences between St. Kitts and the Internet sample, with the St. Kitts participants being somewhat more likely to value heavier women. Notably, however, men and women from St. Kitts were more likely to idealize smaller breasts than participants in the U.S. samples. Attitudes regarding muscularity were generally similar across samples. This study provides one of the few investigations of body preferences in the Caribbean.

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Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France. sankar@iarc.fr

IARC Sci Publ. 2011;(162):257-91.

Population-based cancer survival data, a key indicator for monitoring progress against cancer, are reported from 27 population-based cancer registries in 14 countries in Africa, Asia, the Caribbean and Central America. In China, Singapore, the Republic of Korea, and Turkey, the 5-year age-standardized relative survival ranged from 76-82% for breast, 63-79% for cervical, 71-78% for bladder, and 44-60% for large-bowel cancer. Survival did not exceed 22% for any cancer site in The Gambia, or 13% for any cancer site except breast (46%) in Uganda. For localized cancers of the breast, large bowel, larynx, ovary, urinary bladder and for regional diseases at all sites, higher survival rates were observed in countries with more rather than less developed health services. Inter- and intra-country variations in survival imply that the levels of development of health services and their efficiency to provide early diagnosis, treatment and clinical follow-up care have a profound impact on survival from cancer. These are reliable baseline summary estimates to evaluate improvements in cancer control and emphasise the need for urgent investment to improve awareness, population-based cancer registration, early detection programmes, health-services infrastructure, and human resources in these countries in the future.

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Dan D, Singh Y, Naraynsingh V, Hariharan S, Maharaj R, Teelucksingh S.

Department of Clinical Surgical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago.

Minim Invasive Surg. 2012;2012:427803. Epub 2012 May 8.

 

Bariatric surgery is a well-recognized modality of management of obesity. In addition to obesity, it effectively controls diabetes mellitus, and hypertension. It has been recommended that bariatric surgery should be done in “designated centers” of excellence where there is a high volume of case turnover. Caribbean nations are not spared from the global spread of the obesity epidemic; however, not many patients get the benefits of bariatric surgery. This study aimed to establish that bariatric surgery could be safely and efficiently undertaken in a low-volume center outside the “designated centers” with comparable patient outcomes even in a third world setting. Though “patient numbers” generally imply better outcome, in an environment where these numbers cannot be achieved, patients should not be denied the access to surgery once good outcomes are achieved.

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