Alison L. Wong

Dosage of local anesthesia in wide awake hand surgery.

O NE OF THE MORE NOTABLE recent changes in hand surgery is the method of delivery of the anesthesia. Similar to when they are having a dental procedure, patients who understand and are offered the wide awake alternative like the ideas of (1) no preoperative testing, (2) no tourniquet pain, (3) less time at the hospital to have the surgery, (4) the ability to speak to their surgeon during the surgery, and (5) no sedation to cloud their head when they get home from their surgery.

Modulation of angiotensin II signaling in the prevention of fibrosis.

Over the last decade, it has become clear that the role of angiotensin II extends far beyond recognized renal and cardiovascular effects. The presence of an autologous renin-angiotensin system has been demonstrated in almost all tissues of the body. It is now known that angiotensin II acts both independently and in synergy with TGF-beta to induce fibrosis via the angiotensin type 1 receptor (AT1) in a multitude of tissues outside of the cardiovascular and renal systems, including pulmonary fibrosis, intra-abdominal fibrosis, and systemic sclerosis. Interestingly, recent studies have described a paradoxically regenerative effect of the angiotensin system via stimulation of the angiotensin type 2 receptor (AT2). Activation of AT2 has been shown to ameliorate fibrosis in animal models of skeletal muscle, gastrointestinal, and neurologic diseases. Clinical reports suggest a beneficial role for modulation of angiotensin II signaling in cutaneous scarring. This article reviews current knowledge on the role that angiotensin II plays in tissue fibrosis, as well as current and potential therapies targeting this system.

Local Anesthetics: What's New in Minimal Pain Injection and Best Evidence in Pain Control.

Summary: Local anesthesia in plastic surgery is undergoing a revolution. In the last 10 years, significant improvements in technique have permitted surgeons to do more and more under pure local anesthesia to increase patient safety and convenience while maintaining total patient comfort during the injection of the local anesthesia and while the procedure is accomplished. Many procedures which used to require sedation are now being performed without it. This article explores some of the new advances in local anesthesia such as painless blunt-tipped cannula local anesthetic infiltration, decreased pain with sharp needle tip injection, and long-lasting local anesthetics with delayed release from liposomal encapsulation. This article also examines the best evidence of the last 10 years of advances of pain control with local anesthesia.

Minimally painful local anesthetic injection for cleft lip/nasal repair in grown patients.

Introduction: There has been a recent interest in injecting large body and face areas with local anesthetic in a minimally painful manner. The method includes adherence to minimal pain injection details as well feedback from the patient who counts the number of times he feels pain during the injection process. This article describes the successes and limitations of this technique as applied to primary cleft lip/nasal repair in grown patients. Methods: Thirty-two primary cleft lip patients were injected with local anesthesia by 3 surgeons and then underwent surgical correction of their deformity. At the beginning of the injection of the local anesthetic, patients were instructed to clearly inform the injector each and every time they felt pain during the entire injection process. Results: The average patient felt pain only 1.6 times during the injection process. This included the first sting of the first 27-gauge needle poke. The only pain that 51% of the patients felt was that first poke of the first needle; 24% of the patients only felt pain twice during the whole injection process. The worst pain score occurred in a patient who felt pain 6 times during the injection process. Ninety-one percent of the patients felt no pain at all after the injection of the local anesthetic and did not require a top-up. Conclusion: It is possible to successfully and reliably inject local anesthesia in a minimally painful manner for cleft lip and nasal repair in the fully grown cleft patient.

Surgical Correction of Nonsyndromic Sagittal Craniosynostosis: Concepts and Controversies.

Abstract Sagittal craniosynostosis remains the most common type of isolated craniosynostosis, accounting for nearly half of all nonsyndromic cases. The clinical diagnosis is typically made on the basis of a scaphocephalic head shape and is confirmed by computed tomography or magnetic resonance imaging. The current review examines the major surgical options for correction of isolated sagittal craniosynostosis, including their complications and short- and long-term outcomes. Reconstructive techniques have benefited from advances in perioperative anesthesia monitoring and improved safety of blood transfusion. Although extensive calvarial remodeling is considered safe and may confer greater long-term skull shape correction and decreased neuropsychological sequelae, minimally invasive techniques, such as device-assisted expansion of the cranium continue to increase in popularity. This review underscores the need for additional prospective studies comparing different techniques to determine the optimal reconstructive approach for correction of sagittal craniosynostosis.

The Effect of Written Information on Recall of Surgical Risks of Carpal Tunnel Release Surgery: A Randomized Controlled Study.

Background: Written information has been thought to help patients recall surgical risks discussed during the informed consent process, but has not been assessed for carpal tunnel release, a procedure with the rare but serious risk of complex regional pain syndrome. The authors’ objective was to determine whether providing a pamphlet would improve patients’ ability to remember the risks of surgery. Methods: Sixty patients seen for carpal tunnel release were included in this prospective, single-blind, randomized study. Patients received either a written pamphlet of the risks of surgery or no additional information following a standardized consultation. Two weeks after the initial consultation, patients were contacted to assess their risk recall and whether they had read about the operation from any source. Results: There was no difference in terms of the number of risks recalled between pamphlet (1.33 ± 1.21) or control groups (1.45 ± 1.22; p = 0.73). Recall of infection was better in the pamphlet group (p < 0.05). No patients remembered complex regional pain syndrome. There was no difference in the proportion of people who read additional information about carpal tunnel release surgery between the pamphlet (34.8 percent) and control groups (21.4 percent; p = 0.39), but reading about carpal tunnel release surgery was associated with improved recall (2.45 ± 1.13 versus 0.77 ± 0.91; p < 0.01). Conclusions: Reading about surgery improved risk recall, but providing this information in the form of a pamphlet did not, nor did it affect patients’ ability to recall the risk of complex regional pain syndrome. These results demonstrate that surgeons should implement additional measures to improve comprehension of surgical risks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Assessing Attentional Bias in Secondary Cleft Lip Deformities: An Eye-Tracking Study

Objective: Using a well-established measure of attention, we aimed to objectively identify differences in severity between types of simulated secondary cleft lip deformities. Design: Volunteer participants viewed a series of images of a child digitally modified to simulate different secondary unilateral cleft lip deformities (long lip, short lip, white roll/vermilion disjunction, and vermilion excess), a lip scar with no secondary deformity, or a normal lip. Eye movements were recorded using a table-mounted eye-tracking device. Dwell times for 7 facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face) were compared. Participants: Forty-six naive adults (25 male; mean age 25.5 years) were recruited from our local university community. Main Outcome: The primary outcome of the study was cumulative dwell time between facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face). Results: Participants spent significantly more time focused on the upper lip regions in patients with simulated secondary deformities relative to those who did not (P < .01). Severe short lip deformities resulted in longer fixation times than severe long lips (P < .05). Participants spent less time focused on the eye region in the presence of a secondary lip deformity (P < .05). When total facial fixation time was assessed, short lip deformities resulted in the greatest duration dwell time (P < .001). Conclusions: This study presents objective data to support the concept that observers show varying degrees of attentional bias to the lip region depending on the type and severity of the simulated secondary cleft lip deformity.

Repair of Primary Cleft Palate and Oronasal Fistula With Acellular Dermal Matrix: A Systematic Review and Surgeon Survey

Objective: The current review and survey aim to assess the effectiveness of acellular dermal matrix (ADM) in the repair of cleft palate and oronasal fistula and to evaluate the current trends of ADM use in palate surgery. Design: A systematic review of English articles was conducted using MEDLINE (1960 to July 1, 2016), the Cochrane Controlled Trials Register (1960 to July 1, 2016), and EMBASE (1991 to July 1, 2016). Additional studies were identified through a review of references cited in initially identified articles. Search terms included “cleft palate,” “palatal,” “oronasal fistula,” “acellular dermal matrix,” and “Alloderm®.” An online survey was disseminated to members of the American Cleft Palate-Craniofacial Association to assess current trends in ADM use in palate surgery. Study Selection: All studies evaluating the outcome of primary palate repair or repair of oronasal fistula with the use of aceullar dermal matrix products were included in the review. Results: Twelve studies met inclusion criteria for review. Studies were generally of low quality, as indicated by methodological index for non-randomized studies (MINORS) scores ranging from 7 to 14. The pooled estimate for fistula formation after primary palatoplasty following ADM use was 7.1%. The pooled estimate for recurrence of fistula after attempted repair using ADM was 11%. Thirty-six cleft surgeons responded to the online survey study. Of these, 45% used ADM in primary cleft palate repair, while 67% used ADM for repair of oronasal fistulae. Conclusion: Use of ADM products is commonplace in palate surgery. Despite this, there is a paucity of high-quality data demonstrating benefit. Further randomized controlled trials examining ADM in palate surgery are required to help develop structured guidelines and improve care.

Proximal femur reconstruction using a vascularized fibular epiphysis within a cadaveric femoral allograft in a child with Ewing sarcoma: a case report

Periarticular reconstruction of appendicular bones in skeletally immature patients after tumor resection is a surgical challenge that requires a multidisciplinary approach. The authors present a case of Ewing sarcoma of the proximal femur in an 8-year old girl treated with wide resection of the primary tumor and reconstruction using a vascularized fibula epiphyseal autograft within a cadaveric femoral allograft. The native femoral head was preserved to restore articular anatomy. Postoperative course was without complications. This report demonstrates the use of a vascularized fibula autograft within a cadaveric femoral allograft to optimize growth potential and joint durability in a pediatric patient. ABSTRACT