Ask the Doctor- Surgery

Q: What does "Board Certified Plastic Surgeon" really mean and how can I check to see if my surgeon is "Board Certified?"

Q: Why do we get baggy eyes, and what can we do about it?

Q: I have tattoos that I would like to get removed. Is this possible?

Q: What will take away the dimpled skin after liposuction? Is there a lotion or exercise?

Q: My mother had a stroke and is in the hospital. She feels weak and unable to take care of herself. Her doctor recommends short-term rehabilitation at an acute rehabilitation hospital. She's afraid. Should she be?

Q: Is my lower back pain a symptom of a kidney problem?

Q: Are there newer types of surgeries available for removing kidney stones in men?

Q: My mother is having knee replacement surgery.? What things can I do to make life more comfortable for her when she returns home?

Q: I am having surgery and am more worried about the anesthesia than the surgery. Is anesthesia safe?

Q: I need to have surgery for a hernia. Does this mean I must have traditional surgery? Is laparoscopic surgery an option?

Q: I'd like to have a face lift, but do not want to undergo major surgery. What non-invasive cosmetic surgery options do you recommend and how long do non-invasive surgeries normally last?

Q: What is PAD and how do I know if I am at risk? How is the disease treated?

Q: What advances in medicine are helping athletes recover faster?

Q: A friend told me he has a condition known as Dupuytren's contracture. What is it?

Q: I have been told that I have a Herniated Disc. Does that mean that I need surgery?


Q: What does "Board Certified Plastic Surgeon" really mean and how can I check to see if my surgeon is "Board Certified?"

Medical specialty certification in the United States is a voluntary process. While medical licensure sets the minimum competency requirements to diagnose and treat patients, it is not specialty specific. Certification by an American Board of Medical Specialties (ABMS) Member Board involves a rigorous process of testing and peer evaluation that is designed and administered by specialists in the specific area of medicine.

The American Board of Plastic Surgery was founded in 1938.  In plastic surgery, Board certification requires a minimum of five years of surgical training after graduation from medical school in an accredited training program.  After completion of accredited training in surgery and plastic surgery, the process then involves comprehensive written and oral examinations, as well as submission of the surgical procedures that the surgeon has performed during the year preceding the oral examination.  Physicians' status can be checked by contacting the American Board of Medical Specialties or online at www.abms.org.

Along with Board certification, the Gold Star also demonstrates a physician’s exceptional expertise in a particular specialty and/or subspecialty of medical practice. The Gold Star signals a Board-certified physician’s commitment and expertise in consistently achieving superior clinical outcomes in a responsive, patient-focused setting. Patients, physicians, healthcare providers, insurers and quality organizations look for the Gold Star as the best measure of a physician’s knowledge, experience and skills to provide quality healthcare within a given specialty.

Charles K. Herman MD is Board-certified in plastic surgery and is the Medical Director of Plastic and Reconstructive Surgery at Pocono Medical Center. Dr. Herman practices at Pocono Plastic & Reconstructive Surgery in East Stroudsburg.

Q: Why do we get baggy eyes, and what can we do about it?

One of the most noticeable changes in the face over time is aging around the eyes.  The eyes and the nose are two major focal points of the face.  Aging around the eye can contribute to a tired look in patients, even when they really do not feel tired.  Recent advances in plastic surgery as well as continued research into the anatomy of the eyelids have led to the development of new techniques in rejuvenation of the eyelids, a surgery that is called blepharoplasty.

Changes that occur with aging include loosening of the skin around the eyes; drooping of the skin along the upper eyelid; wrinkles in the skin around the eyes and next to the eyes (called crow's feet); loss of tone of the lower eyelid, which can lead to drooping of the lower eyelid and dryness of the eye itself; and bags under the eyes along with dark circles.  Eyelid bags are caused by the fat pockets of the lower eyelids.  The lower eyelids contain three defined fat pockets; the upper eyelids contain two fat pockets.  Recent studies have demonstrated that the fat pockets can swell with aging.  In addition, the support structures of the lower eyelid, called the orbital septum, can become weaker over time, allowing the fat to bulge.  The combination of these factors can result in baggy eyes.

Newer techniques in plastic surgery address both of these mechanisms that create the prominent bags.  Excess fat that is bulging under the eye is conservatively trimmed through small incisions in the orbital septum.  The orbital septum itself can be tightened or reset as well, further improving the appearance of the lower eyelid.  This surgery can be performed through the inner lower eyelid with no incision onto the skin itself, or through the traditional lower eyelid incision, which is placed right at the edge of the lower eyelid and is virtually invisible with healing.  These techniques are frequently combined with excision of drooping skin and/or muscle of the lower and/or upper eyelids and, if necessary, tightening of the lower eyelid at the corner of the eye to improve its tone, to further enhance the appearance of the eyes.  Sometimes, a chemical peel or lasering of the eyelid skin can also improve the quality of the skin as well as tighten the skin. 

Younger patients in their 30s or 40s may begin to suffer from baggy eyes, which is usually the result of some bulging of the fat pockets but not loosening of the skin:  these patients may be amenable to an incision on the inside of the eyelid only, called a transconjunctival blepharoplasty.  A variety of medical-grade eye creams are also available that can provide modest improvement in the lower eyelid bags and skin wrinkles.  Botox injections can improve the wrinkles along the outside of the eyelids, called the crow's feet.

Charles K. Herman, M.D., is a Diplomate of the American Board of Plastic and Reconstructive Surgery, Medical Director of Plastic Surgery at Pocono Health System, and a member of the faculty of Albert Einstein College of Medicine in New York City.  He is the author of more than 20 chapters and articles in textbooks and journals read throughout the world, on subjects including breast surgery, nose surgery, body contouring, and microsurgery.


Q: I have tattoos that I would like to get removed. Is this possible?

Tattoos are created by injecting various colored pigments into the skin. The pigments are injected at various levels, including the dermis, where they can permanently remain. Tattoos can be either cosmetic or traumatic. Traumatic tattoos occur during an accident when material becomes impregnated into the deeper layers of the skin and trapped there. For example, a deep road rash can cause traumatic tattooing when debris from the road enters the wound. Cosmetic tattoos can vary in their content. Professionally-applied tattoos generally have more durable colors with more uniform penetration into the skin. Amateur tattoos can be less consistent.

Management of traumatic tattoos starts at the time of the injury. It is important to remove as much debris from the wound as possible after the injury to decrease the amount of deformity that results. This includes copious irrigation of the wound with water as well as possible surgical removal of any implanted material. Depending on the type of material imbedded, other types of irrigation solution may be required. For example, we recently had a case at Pocono Medical Center in which a young man had flammable powder impregnated in his face after a firework exploded. This required significant irrigation of the area and even required surgery to remove some of the powder particles, followed by a chemical peel of the skin to further improve some of the discoloration.

Cosmetic tattoos are difficult to remove. Recent advances have demonstrated some improved success. In particular, specific lasers can be used to break up the pigment particles, which are then absorbed by the body. We plan to have such lasers available at Pocono Medical Center this summer. Smaller tattoos may be amenable to surgical excision, but this results in a scar in place of the tattoo. Some pigments may not be completely removed by the laser process and, thus, some of the tattoo may remain after treatment. Several treatments may be required.

Lasering and resurfacing of the skin can be used for other purposes as well. Chemical peels are also effective for resurfacing and improving discoloration. Fine lines and wrinkles can be improved, blemishes and areas of irregular pigmentation can be improved, pore size can be decreased, and overall sun damage can be reversed using these treatments. There also are several lines of medical-grade facial creams and lotions available that can be used at home for the same purposes.

Charles K. Herman, M.D., is an internationally-published, Board-certified plastic surgeon and Medical Director of Plastic and Reconstructive Surgery at Pocono Medical Center. He is the author of over 20 articles and textbook chapters on such subjects as breast surgery, body contouring, nose surgery, and microsurgery.


Q: What will take away the dimpled skin after liposuction? Is there a lotion or exercise?

Answer by Charles K. Herman, MD:

Liposuction is one the most commonly performed cosmetic procedures today.  The procedure involves the removal of fat from the undersurface of the skin using special cannulas, or tubes, that are attached to suction.  Local anesthesia is injected into the areas before the actual suctioning, thus reducing blood loss and pain.  Blood loss typically is minimal.

New variations of liposuction include power-assisted liposuction, which we have available at Pocono Medical Center, and ultrasonic liposuction.  Power-assisted liposuction uses specialized hand pieces attached to a power motor that facilitates the removal of fat. 

One of the more common complications of liposuction is contour deformity, which is irregularity or dimpling of the skin.  This can result from skin that does not contract adequately after the liposuction due to poor skin quality and elasticity, overaggressive or irregular liposuctioning, and liposuction too close to the skin surface. 

Once present, contour irregularities can be difficult to correct.  Methods of improving the areas can include touch-up liposuction, injections of fat or other materials and excision of skin.

 Charles K. Herman MD is Board-certified in plastic surgery and is the Medical Director of Plastic and Reconstructive Surgery at Pocono Medical Center. Dr. Herman practices at Pocono Plastic & Reconstructive Surgery in East Stroudsburg.


Q: My mother had a stroke and is in the hospital. She feels weak and unable to take care of herself. Her doctor recommends short-term rehabilitation at an acute rehabilitation hospital. She's afraid. Should she be?

Answer by James B. Kim, DO, Pocono Medical Center:

Experiencing a stroke can be devastating to anyone. The effects can be even more pronounced in people who, prior to the stroke, had lifestyles that were active and independent. Your mother's fears are understandable, particularly considering that the future is always uncertain (i.e., none of her doctors have a crystal ball).

She should not fear a short-term rehabilitation hospitalization, however. The goal of rehabilitation hospitalization is to restore the person to his/her highest level of function while maintaining and monitoring their acute medical concerns. The fact that your mother has been recommended a rehabilitation program shows that she is starting to stabilize and improve. Rehabilitation is part of the recovery process.

In an acute rehabilitation hospital, physical, occupational and speech therapies are utilized. Recreational and psychological therapies may also be applied, as needed. In addition, some centers may offer complementary and alternative medicines, such as music and art therapies. Each type of therapy is part of a multi-disciplinary team that is led by the attending doctor (usually a physiatrist, or a physician who specializes in Physical Medicine and Rehabilitation). All team members make initial assessments and begin an individual treatment program catered to the person's strengths, weaknesses and medical capabilities.

Typically, team meetings are regularly held to plan for future treatments. This enables all caregivers to have the flexibility to adjust, adapt and change treatments to maximize the person's outcomes, which essentially helps patients “be all they can be.” During your mother's rehabilitation, vigilant medical care and monitoring would also occur, since the initial period of recovery can involve medical complications and/or set backs.

Hopefully, I have answered your question. Your mother should not fear a rehabilitation hospitalization. She should look upon it as the initial steps to recovery.
  


James B. Kim, DO is Board-certified in Physical Medicine and Rehabilitation and is a member of the Medical Staff at Pocono Medical Center. Dr. Kim practices at Dr. Kim’s Rehabilitation Office, located in East Stroudsburg and Wind Gap.


Q: Is my lower back pain a symptom of a kidney problem?

Answer by Umesh Dalal, MD, Pocono Medical Center:

The kidneys are responsible for filtering out dangerous toxins in the bloodstream and performing other functions that are critical to our health, like maintaining hemoglobin in our systems. Uniquely, though, when the kidneys are not working correctly, they rarely exhibit any symptoms. Often referred to as a silent killer, kidney disease slowly afflicts people without producing any symptoms. Therefore, back pain or other symptoms that are often falsely associated with the kidneys are rarely symptomatic of a kidney problem.

In fact, the only way to tell if your kidneys are working properly is by having a blood test. From the blood test, your doctor can determine how much creatinine, a waste product, is in your blood stream. The lower the levels of creatinine, the better the kidneys are functioning. In contrast, high amounts of creatinine are indicative of impaired kidney function. If detected early enough, your physician can help you manage the disease.

Kidney disease is quite common; in this country alone, kidney disease afflicts about 11% of the population, and its frequency continues to rise worldwide. The earlier the disease is detected, the better the chance for non-invasive treatment and survival. Unfortunately, undiagnosed kidney disease often leads to other cardiovascular diseases and can progress into kidney failure, in which case the only options for survival are kidney dialysis, an invasive and expensive treatment, or kidney transplant, which typically requires a two-year waiting period (unless the patient finds a donor on their own).

The two most common causes of kidney disease are diabetes and high-blood pressure. Therefore, anyone with these diseases or a family history of these diseases should have a blood test to determine if their kidneys are functioning properly. Controlling glucose levels and keeping blood pressure levels low can help prevent the onset of kidney disease or, if it has already begun, help slow its progression. Once the disease has set in, patients have limited—if any—treatment options. Therefore, early screening and detection are critical to ensuring the health of your kidneys and, consequently, your overall wellbeing. 
 


Umesh Dalal, MD is Board-certified in Nephrology and a member of the Medical Staff at Pocono Medical Center. Dr. Dalal practices at Pocono Medical Group & Nephrology Consultants in East Stroudsburg.


Q: Are there newer types of surgeries available for removing kidney stones in men?

Answer by Michael Eufemio, MD, Pocono Medical Center:

Advances in research and medicine have led to newer, less invasive methods for treating kidney stones, which are solid masses that form in the kidney from minerals in the urine. 
Fortunately, many of today’s treatments are minimally invasive, meaning that patients recover quickly and experience smaller or, in some cases, no incisions. The type of treatment for kidney stones is dictated by the size of the kidney stone and where the stone is located.

Kidney stones can range in size from as small as a grain of salt to as large as a golf ball. Smaller stones  (i.e., those that are 5 millimeters or less in size) can usually be naturally passed through the patient’s system without a great deal of pain.  If the stones are passable, then the patient is often advised to consume excess fluids and can be prescribed pain medication.

Although some people can pass stones that are larger than 5 millimeters in size, certain conditions, such as having signs of infection (i.e., a fever), nausea or vomiting and persistent pain, will require the stones to be removed surgically. Larger stones, which can become stuck in the bladder or ureter and block the flow of urine, would also need to be removed surgically. 

In addition to size, the location of the kidney stone is another key factor in determining the type of treatment that is necessary. Kidney stones that are located in the lower urinary track, for instance, are often removed with telescopes or endoscopes that are placed into the natural urine canal, which means that no surgical incisions are necessary. This outpatient procedure only takes less than an hour and a temporary plastic tube (or stent) is placed in the urinary track to allow for post-operative healing. Afterward, the stent can be removed in the doctor’s office. 

Larger stones in the urinary track or in the kidney are generally treated with laser or shockwave lithotripsy. Lithotripsy, which is Greek for “stone breaking,” uses energy waves that are transmitted through a machine to the patient’s body. This energy breaks the stone into smaller pieces and, after the procedure, the pieces can be spontaneously passed.

Very large kidney stones can be treated with percutaneous nephrolithotripsy. In this procedure, the physician (usually a urologist) makes a small, one-inch incision and a telescope or tube is inserted directly into the kidney. The stones are broken into smaller pieces using various energy sources, such as ultrasonic and laser energy, and the pieces are removed through the telescope.  This operation, which only requires 2-3 days of hospital stay and about a week of recovery time, allows us to treat larger stones without having to perform a more extensive or “open” operation. 

Ultimately, the composition of the kidney stone and its location will dictate what treatment works best. However, many patients can be treated with minimally invasive modalities as opposed to having to undergo major surgery. To determine the best treatment option for you, it is important to speak with your physician about your condition.

Michael Eufemio, MD is Board-certified in Urology and is the Chief of Urology at Pocono Medical Center. Dr. Eufemio practices at the Urology Associates of the Poconos in East Stroudsburg and at the Mountain Healthcare Center in Tobyhanna.


Q: My mother is having knee replacement surgery.  What things can I do to make life more comfortable for her when she returns home?

Answer by Frederick J. Barnes, MD, Pocono Medical Center:

Degenerative joint disease, also known as osteoarthritis, affects more than 20 million Americans. Patients with disabling arthritis of the knees that have failed conservative treatment may benefit from total knee replacement.  The operation entails the surgical excision of the arthritic joint surfaces and replacement with a prosthesis made of metal and polyethylene. 

Usually, the patient is allowed to bare weight almost immediately after surgery, then begins a course of rehabilitation, which lasts anywhere from several weeks to several months, depending on the patient.  During this time, the patient works on regaining the strength and range of motion of the knee.

When the patient returns home, it is important to make sure that the home is a safe environment, and one way that can be done is to perform an inspection. It is important to make sure there are no loose electrical cords or floor coverings that may cause the patient to trip.  Also, it is important to make sure that the furniture is spaced widely enough so that the patient can negotiate the hallways and living quarters safely.

Two areas of the house where the patient may spend a significant amount of time are the bathroom and the kitchen.  In the bathroom, the addition of a high toilet seat and shower chair could be very helpful.  The kitchen should be uncluttered and the flooring should be stable.  It is commonplace to enlist the assistance of a home care agency that will help in the inspection of the home and offer advice and expertise to facilitate the transition from hospital to home. 

Fortunately, in the great majority of patients, modern total knee replacement allows the patient to regain function as well as decrease the discomfort associated with severe degenerative joint disease.

Frederick J. Barnes, MD is Board-certified in Orthopedic Surgery. He is Chief of Orthopedic Surgery and a member of the Medical Staff at Pocono Medical Center. Dr. Barnes practices at the Mountain Valley Orthopedics in East Stroudsburg and at the Mountain Healthcare Center in Tobyhanna.


Q: I am having surgery and am more worried about the anesthesia than the surgery. Is anesthesia safe?

Answer by Anthony Nostro, MD of Pocono Medical Center:

Although it is common to experience some anxiety concerning the anesthesia portion of your surgery, you should take comfort in knowing that recent advances in technology and medicine have made anesthesia safer today than ever before.

Having a basic understanding of anesthesia might help alleviate your fears. Generally speaking, there are three types of anesthesia: general anesthesia, which prohibits sensation throughout the entire body; regional anesthesia, which prevents sensation throughout a certain section of the body; and local anesthesia, which is used to block sensation in a very specific or “localized” area of the body. 

Whether general, regional or local, anesthesia entails more than just numbing the body, however. Different anesthetics can be used for specific purposes, including hypnosis (induction or sleep), amnesia (forgetting that one is having surgery), analgesia (pain relief), and paralysis (muscle relaxation). The degree to which each of these components is, or is not, present in the anesthetic is determined by the type of surgery as well as the patient’s condition and preference.

Improvements and advancements in medicine have made today’s anesthetics much safer and shorter-acting. As a result, patients are able to recover faster and return to their normal lifestyles sooner. Some anesthetics also have anti-nausea and anti-vomiting properties, which adds to the patient’s comfort.

Your anesthesia will be based on the type of surgery you’re having as well as your medical condition and overall health. In order to ensure that you receive the anesthesia that is best for you, an anesthesiologist (i.e., a physician whose specialization is anesthesia) or a certified registered nurse anesthesiologist (also known as a CRNA, a nurse with specialized training in anesthesia) will carefully review your medical history prior to the surgery. Your anesthesiologist will also consult with you to discuss any of your concerns as well as any pre-existing medical conditions that might impact the anesthesia.

Depending on the type of surgery you are having, either an anesthesiologist and/or a CRNA will be present throughout the entire procedure to monitor your anesthesia.  In addition, there are a number of precise, technologically advanced monitors that are used during the surgery to gauge important factors like your blood pressure, cardiac functioning, oxygen levels and depth of anesthesia. This technology, along with the guidance of the anesthesiologist and/or CRNA, will provide careful and consistent monitoring throughout your surgery. 

If you stay overnight, after your surgery you can expect a visit from a member of the hospital’s anesthesia department. During this postoperative evaluation, you will be examined and questioned to ensure that you are recovering safely.

Anesthesia nurses and physicians are trained to be partners in the patient’s health and safety. We are held to the highest ethical and professional standards, and we are given specialized, graduate-level training in anesthesia. As your surgery nears, rest assured that the high standards of today’s anesthesia professionals, coupled with the advances in modern technology and medicine, make anesthesia one of the safest components of your surgery.  

Anthony Nostro, MD is a Board-certified anesthesiologist and the Medical Director of Anesthesia at Pocono Medical Center.


         
Q: I need to have surgery for a hernia. Does this mean I must have “traditional” surgery? Is laparoscopic surgery an option?

Answer by Boris Paul, MD of Pocono Medical Center:

For almost two decades, surgeons have been using the less invasive laparoscopic approach as an alternative to performing many traditional or “open” surgical procedures (i.e. kidney, gallbladder and colon surgeries, to name a few). Using the laparoscopic technique to perform hernia surgery is no exception; surgeons have been performing laparoscopic hernia surgery for quite some time.

The laparoscope, which is a small, telescope-like instrument that contains fiber optics (lights) and a camera, is the hallmark of the laparoscopic procedure. We insert the scope along with microscopic instruments through three very small incisions, each being the size of a nickel or smaller. Guided by the images captured on a screen by the laparoscope, the surgeon performs the operation in approximately twenty minutes. The recovery time for patients is also extremely short, requiring only a few hours of postoperative rest, and patients typically go home the same day. After the surgery, there are no postoperative restrictions like lifting or driving. Patients are simply asked to take preventive measures against any actions that might increase the pain from the surgery.

The advantages of laparoscopic hernia surgery are the same as other laparoscopic procedures: less pain, shorter hospital stays, faster recovery times, along with a decreased chances of infection, nerve injury and damage to the surrounding tissue. The small incisions of the laparoscopic approach also leave much shorter, less traumatic scars.

The traditional or “open” hernia surgery, however, requires a large incision across the groin, and has greater chance of infection as well as nerve injury, chronic pain in the groin (with the chance of becoming incapacitated) and a much longer recuperation period.

Unequivocally, laparoscopic surgery has many advantages over the older, more traditional approach. It is therefore highly recommended that you inquire about having your hernia surgery performed laparscopically. The laparoscopic surgery will ultimately save you much unnecessary time and pain, while still providing outstanding results.

Dr. Paul is a Board certified surgeon and is a member of the Medical Staff of Pocono Medical Center. He practices at Pocono Surgical Associates in East Stroudsburg.



Q: I'd like to have a face lift, but do not want to undergo major surgery. What non-invasive cosmetic surgery options do you recommend and how long do non-invasive surgeries normally last?

A: Many patients would like to avoid the longer recovery times and more involved surgery associated with a full face lift. Recent developments in the field of plastic surgery have made this possible. Less invasive procedures range from office procedures such as injectable medicines and chemical peels to minimal scar facelifts, or "minifacelifts." Procedures that can be performed in the office include Botox, Restylane, Perlane, Alloderm, and chemical peels.

Botox is a medicine that works to reduce wrinkles and lines along the face, especially around the eyes, nose, and forehead by selectively blocking the muscles that cause these wrinkles. The effects typically last up to 6 months. Restylane is very popular. It is an injectable material that made in the laboratory and is used to fill in lines, wrinkles, and creases in the face that are associated with aging. It is also commonly used to enlarge the lips and is most popular for the nasolabial folds, which are the lines between the nose and lips that almost deepen with aging. It also lasts about 6 months. Perlane just became available in the United States. I performed the first injection of this material in this area in early June in a television broadcaster who desired improvement of the lines next to her nose but needed to return to work the next day. It resembles Restylane, but can provide a more dramatic effect with more fullness provided by its different formulation. Alloderm is a skin product that can be injected or placed surgically under local anesthesia; it can provide longer-lasting results, even for years.

Chemical peels can range from 10-minute procedures performed in the office to deeper peels performed in the hospital that require anesthesia. The office-based peels are very popular; after some, patients can return to work even the same day. Different types of peels are available, including glycolic acid and TCA peels, which provide differing effects depending on patients' needs and desires. They can effectively reduce fine lines and wrinkles in the face, as well as improve complexion. These medical-grade peels are not available in the typical "spa," as they must be given by a doctor, and provide a much better result in most cases than those available in spas.

We also have a full line of medical-grade facial products, including eye creams, toners, peeling agents, and cleansers available through the office that are only available through medical providers.

Several new operations have become available in the past few years that can provide a significant improvement in facial aging while avoiding the longer operative time and recovery of a full facelift. I conducted, with another surgeon at Albert Einstein College of Medicine in New York City, a study of 30 patients who underwent a lift using stitches placed through small cuts along the face. The stitches were strategically placed to provide a lift to the sagging tissues in the face. Variations of this technique have been described, including the "Contour Lift." We plan to publish our results in the next few months. The so-called "minifacelift" is the most common minimal scar facelift that I perform today. The scars are limited to around and inside the ear. The recovery period is about one week for most of the swelling and bruising to resolve.

As patients are increasingly motivated to have procedures that are shorter with reduced recovery periods, new procedures will continue to be developed and existing procedures will evolve. More information about these procedures is available on our Web site at www.poconoplasticsurgery.com.

You can also learn more about minimally invasive cosmetic surgeries in an upcoming issue of Progress, Pocono Medical Center's magazine, which will be devoted exclusively to the latest trends in surgery. Progress is available for free at Pocono Health System locations throughout the community and online at: www.poconohealthsystem.org.

Dr. Charles Herman is Medical Director of Plastic Surgery at Pocono Medical Center and an Attending Surgeon at Albert Einstein College of Medicine in New York City. He is an internationally-published author of multiple journal articles and textbook chapters, a lecturer at meeting and schools across the country, an award-winning researcher who has received research and clinical awards from the American College of Medicine, and is Board-Certified by the American Board of Plastic Surgery.


Q: What is PAD and how do I know if I am at risk? How is the disease treated?

A: PAD is peripheral artery disease. It is a condition in which arteries in the legs and pelvic area stiffen and narrow as they become blocked by plaque. The lack of blood flow to muscles causes aching pain while walking, called claudication, and can lead to loss of mobility or amputation. Those with PAD are seven times more likely to have a heart attack or stroke, because when leg arteries are blocked, other blood vessels usually are too. Although more than 12 million Americans suffer from the disease, one of the biggest problems with PAD is that many people who have the condition do not seek medical attention early enough. A common mistake is patients attribute their difficulty walking and their aching legs to age rather than disease.

The risk of developing this condition increase with age, and according to the U.S. Census Bureau, it affects approximately 20 percent of the U.S. population over 70. As the older population continues to grow, so will the occurrence of PAD. Smokers are diagnosed with the disease three times more often than non-smokers. Other risk factors include people with diabetes, coronary artery disease, hypertension, high cholesterol, obesity and family history. Symptoms of PAD include, but are not limited to the following: numbness or tingling in the lower extremities; cramping and pain through the lower half of the body; skin feeling cold to the touch; bluish or reddish discoloration; sores that do not heal; and weakness in the limbs. 

Patients who seek treatment with the SilverHawk have remarkable success in gaining back their mobility and quality of life. The longevity of results for plaque excision, combined with its minimally invasive procedure, makes it a true revolution in vascular health.

Stents, angioplasty and open bypass surgery are treatment options; however, these procedures provide only temporary relief and patients often return within six months to have the procedure repeated because plaque has again blocked the artery. Patients can now have more permanent results with a minimally invasive procedure called plaque excision, using the SilverHawk Plaque Excision System. The SilverHawk device uses a razor the size of a grain of rice to shear the plaque off the walls of clogged arteries. The advantage of this technique is that it does not stretch and traumatize the artery the way balloon angioplasty and stents may, which can lead to further complications.

During the procedure, the electric-powered SilverHawk device is inserted into the artery through a catheter in the groin, without incision. Once inside the artery, the doctor activates a tiny rotating blade to shave off the plaque, milligrams at a time. The plaque collects in a cone that is removed when the catheter is withdrawn. Some patients require the catheter to be inserted and withdrawn several times, to ensure the artery is open. Contrasting dye is used to determine when the artery has been cleared. Even when multiple insertions are necessary, the procedure lasts approximately 20 minutes to one hour.

This treatment is only used for narrowed and blocked arteries in the legs, which can be harder to clean than heart arteries, because legs often develop restenosis, a quickly forming reblockage of scar tissue or new plaque. Plaque excision is preferred as a first option, because it allows for future treatment options. If this fails to unblock the artery, the patient still has many other options. With bypass, if it fails, you can lose the limb.

The SilverHawk procedure is a breakthrough in healthcare, since other more invasive surgeries required a patient to be healthy enough to undergo a complex surgery. Now, patients who have other illnesses or health complications can get relief for their legs without having a complex operation. In fact, recovery is so minimal that patients usually get up and walk immediately following the procedure.

Boris Paul, MD


Q: It seems as if athletes are able to recover much quicker from sports injuries than ever before. What advances in medicine are making this possible?

A: Joint injuries are common among athletes, and until recently, treatment required large incisions, prolonged hospital stays and sometimes wearing a cast for several months. Today, thanks to arthroscopy, a minimally invasive outpatient procedure, treatment is reduced to tiny incisions, less pain and faster recovery times.

Arthroscopies are performed mostly on shoulders and knees. An arthroscope, the instrument used to diagnose the problem, is a small, pencil-sized device with a miniature video camera on the end. The physician first makes small holes around the injured joint, fills the area with fluid and then inserts the arthroscope. The doctor makes the necessary repairs using motorized and non-motorized micro-instruments, guiding them by the image on a video monitor.

A variety of shoulder injuries can be treated using arthroscopy. One common injury is the rotator cuff, which often has a hole. Using arthroscopic instruments, the physician can remedy the problem by suturing. Tendonitis, which is also common, occurs when there is a spur on the acromion, which the physician shaves off arthroscopically.

Knees are also subject to many common injuries, such as torn menisci, or torn cartilage, and torn ligaments. Damage to the articular surface — the covering of the knee — is being diagnosed more frequently because it is now more recognized. Using a new arthroscopic procedure called mosiacplasty, the surgeon takes pieces of the joint surface from a location in the knee and replaces it in the injured areas. Again, this procedure means less pain and faster recovery time.

Arthroscopy is also used to remove bone chips from any joint, including the ankle, wrist and elbow. The procedure is valuable in assessing the bones’ alignment in a wrist fracture, and in removing damaged tissue then repairing a structure that supports the small bones in the wrist. -  Gregory Menio, M.D.

Dr. Amit Gupt


Q: A friend told me he has a condition known as Dupuytren’s contracture. What is it?

A : Dupuytren’s contracture is a malady that affects mostly men of northern European decent. No one knows the cause or why it affects six times more men than women. The condition occurs when the fibrous tissue beneath the skin of the palm and fingers thickens, causing a long cord to form. The fibrous cord pulls the fingers — usually the ring and little fingers — into a bent position. Sometimes anticonvulsive medication causes the problem, although, again, the reasons are unknown. The treatment for the condition is surgery.

Dr. George Primiano


Q: I have been told that I have a Herniated Disc. Does that mean that I need surgery?



A: A disc herniation (also known as a herniated nucleus pulposus or HNP) is when the shock-absorbing disc between your vertebrae (spinal bones) protrudes outwards, sometimes with extrusion of the gelatin-like center material. The problem develops when the disc compresses or lies on a nerve. This is called a radiculopathy, and it can give you shooting pains as well as weakness in a limb. It is the combination of the severity of the disc herniation, the severity of the symptoms, and the outcomes of the non-surgical treatments that will determine whether or not surgery should be performed.
 
Statistically, most herniated discs can be successfully treated non-surgically. Initial treatments include rest, medication and physical therapy (or at least performing at-home exercises).
You're usually given a trial of about one to three months on this regimen. Depending on how severe your symptoms remain, the next avenues of treatment may include different types of injections, such as epidural steroid injections. If another portion of your back is involved, such as the facet joints, then a facet joint injection may be offered.

If injections are chosen, it is recommended that specialists who have added board credentialing for pain management perform the injections. Several existing specialties have this extra credentialing, including anesthesiology, neurology, and physical medicine and rehabilitation. Interventional radiologists can also perform these injections, as the injections are generally performed under radiological guidance.

It is important to note, however, that the non-surgical treatments do not reduce the disc herniation; their goals are to reduce the symptoms so that you can live with the disc herniation. Over time, disc herniations will eventually shrink on their own through a degenerative process of drying out, known as desiccation.
 
Patients should also be advised that the aforementioned treatments could be utilized for disc herniations in the neck (cervical), mid back (thoracic) or low back (lumbar). If the non-surgical treatments fail to alleviate your symptoms, then a spinal surgical evaluation would be in order.

Generally, surgery is recommended when the disc is in a position that is compressing a nerve root and is causing symptoms of pain, burning, tingling or numbness in a corresponding arm or leg (this is called a radicular symptom).

More urgent calls for surgery include profound weakness in a corresponding limb, spinal cord compression, loss of control of urination or defecation or numbness in your anogenital area (saddle numbness). Fortunately, though, these last circumstances are rare.
 
In conclusion, most disc herniations do not require surgery and can improve with conservative management.

James B. Kim, DO is Board certified in physical medicine and rehabilitation and is a member of the Medical Staff of Pocono Medical Center. Dr. Kim practices at Dr. Kim’s Rehabilitation Office, located in East Stroudsburg and Wind Gap.

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