Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments

Case Report: Surgical Removal Of A Muffin Top

"Muffin Top" Excision

At ten months of age I had a life-threatening condition that required risky abdominal surgery. The pediatric surgeon had to open my belly from end to end, right above my umbilicus. I lost most of my colon in the process, but the only apparent long term effect was an impressive seven-inch scar. After forty years of living, the scar had become “stuck,” resulting in a preponderance of skin slowly increasing its droop over the old gash. Basically, I had a non-clothing-induced “muffin top” and no amount of diet and exercise would improve it.

So off I went to the plastic surgeon, knowing that he couldn’t erase the scar but could improve the contours of my abdomen. In effect, I could retain my current appearance (that of a woman who had a permanent belly indentation caused by a lifelong history of wearing high-waisted pants that were two sizes too small) or I could opt for surgery and embody the look of an athlete who had picked a fight with Zorro. The choice was clear. I would settle for the long slice on a thin belly.

The problem with being a doctor under the knife is that you know exactly what the other guy is doing. This procedure was completed under local anesthesia, and so I was chattering away with my surgeon the entire time. Although it took us at least half an hour to numb the area, I could still feel every tug and pull, hear the click of forceps, and the crunch of clamps. It was a little unnerving to have one’s abdominal flesh wide open to the world – something I’d only expected of my patients previously. So my surgeon snapped a photo for my blog (see above) though I opted out of looking at the image in the middle of the procedure. I have my limits.

So why am I sharing this with you, dear readers? Well, I do have a few tidbits of advice for anyone who is planning to undergo a substantial cosmetic surgery under local anesthesia. I hope these are helpful:

1. Wear a comfortable pair of undies. The unisex/unisize disposable options available at the surgical suite do provide comic relief – if you think you’ll be needing that. The pair that I received were the color and texture of surgical booties and about the right size for a guy in the WWE.

2. Try not to kick the surgical assistant(s) during the numbing portion of the procedure (or during any other portion come to think of it). Let’s face it, lidocaine hurts. Each injection feels like a bee sting, and if you’ve got a lot of surface area to cover, you’re going to be spending the first half hour (or more) squeezing something with great vigor. Which leads me to my next tip:

3. Find something firm to grip during the procedure. I found the surgical table arms to be nicely padded and an adequate thickness for death grips. I did wonder if I should have brought one of those “stress balls” with me, or perhaps a pair of hand grip strengtheners from a local gym (see image to the left).

4. Be prepared to make small talk with your surgeon for an hour or more. Preparing some “talking points” in advance could have made my patter more amusing, I suppose. But the art of distraction is a valuable asset in wide-awake surgeries. Your nervousness may actually make you a little extra charming, so don’t worry about what you say. Just do what it takes to keep your mind off the situation.

5. Don’t put your hands in the sterile surgical field. At certain times during the procedure your surgeon is likely to happen upon a spot that isn’t fully numb. You will probably respond with a squeal (or kick) and a loud “Ow!” The surgeon will then ask you what you are feeling and you must resist the urge to show him/her by pointing at it. Many an abdominal wound has been accidentally poked by well meaning patient fingers. Be careful! Just say you feel something sharp and the surgeon will know where it hurts… because he/she just did something to cause the reaction!

6.  Get detailed post-op wound care instructions. You’ll probably exit the surgical suite with a lot of gauze and tape all over you, and it will occur to you later on that you haven’t the faintest idea when it’s safe to remove it. Can it get wet? Should you remove the steri strips? When do the stitches come out? When should you begin to use silicon scar gel? Do you need neosporin? Make sure you ask these questions before you’re released back into the wild.

7. Ask about movement restrictions and exercise precautions. You may be surprised by how restricted your movement should be in the first two weeks after surgery. I guessed that back flips would be counter-productive in my case, but didn’t realize that I couldn’t “walk fast” or twist at the waist. Make sure you understand what you can and can’t do to optimize your healing.

8. Take some pain medicine at least an hour before the local anesthetics are due to wear off. This was my biggest mistake. I asked if the wound would be painful later on and my surgeon denied any knowledge of potential post-op pain. So, six hours later when I felt as if someone had attacked my belly with a blow torch, I found some comfort in a maximum dose of ibuprofen and a vodka martini (and for those who know me well – yeah, I couldn’t finish the martini because it tasted gross).

9. Keep the scar protected and moist. Healing skin loves to be moist, especially early on. Ask your surgeon how best to accomplish that.

10. Get the stitches out on time. Don’t leave them in too long or you will be at risk for a larger or thicker scar. Disolvable stitches are convenient, but they do cause more inflammation which can lead to larger or more robust scar formation.

11. Tell your surgeon that you love the results (if they’re good!!) He/she will really appreciate the feedback.

I’m very pleased to report that my abdominal recontouring was a success, and I hope you’ll learn from my mistakes if you’ve got one coming up. Now I must strive to keep a new muffin top from growing by eating a healthy, calorie controlled diet (excluding real muffins!?) and exercising regularly. ;-)

You may also like these posts

Read comments »

Comments are closed.

Return to article »

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

Read more »

See all interviews »

Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


Click here for a musical take on over-testing.

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »