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rehabilitative therapy, aversion treatment, the use of disul ram (Antabuse), and the participation in self-help organizations for recovery from alcoholism Detoxi cation clinics and special hospital units for the treatment of alcoholism are now widely available The physician should be fully aware of all the community resources available for the management of this problem and should be prepared to take advantage of them in appropriate cases Most inpatient programs include individual and group counseling, didactics about the illness and recovery, and family intervention Outpatient treatment (of individuals or groups) is widely available, either from specialized facilities or from specialized therapists in general mental health facilities; family counseling is usually offered as well and is often bene cial Most professional alcoholism treatment in the United States includes an introduction to the methods and utilization of Alcoholics Anonymous (AA, see later) Disul ram interferes with the metabolism of alcohol, so that a patient who takes both alcohol and disul ram accumulates an inordinate amount of acetaldehyde in the tissues, resulting in nausea, vomiting, and hypotension, sometimes pronounced in degree It is no longer considered necessary to demonstrate these effects to patients; it is suf cient to warn them of the severe reactions that may result if they drink while they have the drug in their bodies Treatment with disul ram is instituted only after the patient has been sober for several days, preferably longer It should never be given to patients with cardiac or advanced liver disease Should the patient drink while taking disul ram, the ensuing reaction is usually severe enough to require medical attention, and a protracted spree can thus be prevented Disul ram may cause a polyneuropathy if continued over months or years, but this is a rare complication Several other drugs have recently become popular in maintaining abstinence The opioid antagonist naltrexone (50 mg/day) has been used for this purpose, with mixed but overall favorable results In Europe, a modicum of success has been achieved with the GABA and glutamate modulator acamprosate (2000 mg daily), but this drug is not yet available in the United States Putatively, a novel approach has been to block the addicting effects of alcohol on the mesolimbic dopaminergic system by the use of anticonvulsants such as topiramate Johnson and colleagues were able to demonstrate a reduction in alcoholic intake in patients taking this drug, in comparison to placebo, albeit over only a 12-week period The use of these medications and the possible reasons for con icting results between studies are given in a thorough review by Swift Alcoholics Anonymous, an informal fellowship of recovering alcoholics, has proved to be the single most effective force in the rehabilitation of alcoholic patients The philosophy of this organization is embodied in its 12 Steps, a series of principles for sober living that guide the patient to recovery The AA philosophy stresses in particular the practice of making restitution, the necessity to help other alcoholics, trust in a higher power, the group confessional, and the belief that the alcoholic alone is powerless over alcohol Although accurate statistics are lacking, it is said that about one-third of the members who express more than a passing interest in the program attain a state of long-sustained or permanent sobriety The methods used by AA are not acceptable to every patient, but most who persist in its activities appear to bene t; in particular, the physician should not accept a patient s initial negative reaction as reason to abandon AA as a mode of treatment Finally, it should be noted that alcoholism is frequently associated with psychiatric disease of other types, particularly socio-.

pathy and affective illness (the term dual diagnosis is used by psychiatrists to denote this combination of psychopathologies) In the latter case, the prevailing mood is far more often one of depression than of mania and is more often encountered in women, who are more apt to drink under these conditions than are men In

these circumstances, expert psychiatric help should be sought, preferably from someone who is also familiar with addictive diseases The role of physicians in caring for patients with alcohol problems has been outlined by several governmental agencies and are summarized in the review article by O Connor and Schottenfeld

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biological material may be disposed of easily and the amount of aspirated fat may be measured by the graduations on the side Some surgeons still use specially designed syringes (tulip system) in which a gentle vacuum in the syringe is manually used to withdraw the fat In their areas, a variety of surgical cannulas are available It is advised that inexperienced dermatologic surgeons use a more conservative cannula, which includes smaller blunt-tipped cannulas with side ports More experienced surgeons may prefer the more aggressive instruments having multiple openings at the tip of the cannula These socalled more aggressive cannulas are more likely to rupture neurovascular bundles and increase bleeding For smaller areas or for repeat touch-up procedures, the Klein microcannulas are helpful These are very small in size and a multiple puncture technique can be used The microcannulas are placed speci cally in focally fatty areas in order to facilitate removal of abdominal fat These are very helpful in small areas, especially around the periumbilical area It is important to note that the fat aspirate is remarkably free of blood when the Klein microcannula methods are used The cannula is constantly moved in a to-and-fro fashion through the subcutaneous space with the dominant hand The nondominant hand is used to palpate the area of the body undergoing liposuction surgery This nondominant or smart hand can be used in a at manner in order to stabilize the tissue with the dominant hand guiding the cannula underneath it Alternatively, the nondominant hand can cup the skin in between it and the cannula used to suction the pocket of subcutaneous fat held in between the two skinfolds It is important to remember the principles of crisscross cannula movement A triangular pattern of suctioning occurs, and these fanning patterns are used to overlap so that there are multiple tunnels created from several entrance sites overlapping one another Deep tunneling is often begun initially, later leading to super cial tunneling It is important to remember when working in the abdomen to suction deep to Scarpa s fascia, which ensures complete fat removal and an even approach to the removal of the subcutaneous fat.

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