Article

Optimal Time Delay between Epinephrine Injection and Incision to Minimize Bleeding

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Abstract

Background: The time until maximal cutaneous vasoconstriction after injection of lidocaine with epinephrine is often given in textbooks and multiple choice examinations as 7 to 10 minutes. However, in our experience, there is significantly less cutaneous bleeding if one waits considerably longer than 7 to 10 minutes after injection of local anesthesia with epinephrine for most procedures on human skin. Methods: This was a prospective, randomized, triple-blind study where 12 volunteers were injected simultaneously in each arm with either 1% lidocaine with epinephrine (study group) or 1% plain lidocaine (control group), after which the relative hemoglobin concentration of the underlying skin and soft tissues was measured over time using spectroscopy. Results: In the epinephrine group, the mean time at which the lowest cutaneous hemoglobin level was obtained was 25.9 minutes (95 percent CI, 25.9 ± 5.1 minutes). This was significantly longer than the historical literature values of 7 to 10 minutes for maximum vasoconstriction after injection. Mean hemoglobin index values at every time measurement after postinjection minute 1 were significantly different between the study group and the control group, with use of a two-tailed paired t test (p < 0.01). Conclusions: If optimal visualization is desired, the ideal time for the surgeon to begin the incision should be 25 minutes after injection of local anesthetic with epinephrine. It takes considerably longer than 7 to 10 minutes for a new local equilibrium to be obtained in relation to hemoglobin quantity.

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... However, using spectroscopy in the arm skin of healthy volunteers, McKee et al. reported that the lowest haemoglobin level was seen after 26 min. 3 In a later study, they measured bleeding in skin during carpal tunnel surgery, and found a significant decrease after 30 min. 4 No studies have been carried out in which the amount of bleeding has been determined quantitatively at many different times following the administration of local anaesthetics with epinephrine. ...
... This is in good agreement with empirical knowledge and the general practice of waiting 7-10 min, 2 and in direct contrast to the results presented by McKee et al., where a waiting time of 30 min was required to achieve maximal haemostasis. 3,4 There is a noted discrepancy between the results of this study and the work done by Mckee et al., but there are some differences in the experimental methodology. Mckee et al. used micropipettes, while we used weighing off surgical swabs for blood loss quantification. ...
... Assuming that epinephrine exerts the same effect in humans, this confirms that the common clinical practice of waiting 10 min before surgical incision is appropriate and challenges the results of studies where a 30 min delay has been reported. 3,4 ...
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Objective: Based on clinical experience gained over many years, the maximal haemostatic effect following administration of local anaesthetics containing epinephrine is generally believed to occur within 10 min. Surprisingly, it was found in a recent study, in which bleeding was quantified intraoperatively, that maximal haemostasis did not occur until 30 min. If this is indeed the case, then it would be necessary to extend the preoperative waiting time to minimize perioperative bleeding.We have carried out a carefully controlled study on the time delay between administration of a local anaesthetic containing epinephrine and maximal haemostasis in a surgical setting. Methods: Lidocaine 20 mg/ml (2%) or lidocaine + epinephrine 12.5 µg/ml (1:80,000) was injected into the skin of eight pig flanks. Bleeding was induced after 3, 5, 7, 15 and 30 min by making a 10 mm incision at each injection site. Blood was collected for 1 min and weighed. Results: A gradual reduction in bleeding was observed, with maximal reduction after only 7 min (54%, p < 0.05, 95% CI: 44-64%). No further significant reduction in bleeding was observed (62% at 15 and 66% at 30 min, p = n.s. compared to 7 min). Conclusions: Maximal haemostatic effect in the current setting was observed within 7 min of injection of lidocaine with epinephrine. This is in good agreement with previous empirical findings, and we see no reason to prolong the preoperative waiting time.
... This timeframe is sufficient for a complete sensory block but does not allow epinephrine's vasoconstrictive properties to take full effect. 12,13 In the tourniquet-free technique, local anesthetic plus epinephrine is injected in the surgical site before entering the operating room, thereby allowing epinephrine to take full effect. Once in the room, the patient's arm is disinfected and draped in a similar fashion, and surgery proceeds without inflation of the tourniquet. ...
... The optimal effect of epinephrine, which enables maximal vasoconstriction and hemostasis of the surgical field, has been proven to be >25-30 minutes after local injection as opposed to the 7-minute wait traditionally taught. 12,13 Waiting for the maximal effect of epinephrine before the first incision has shown a threefold reduction in bleeding compared with a shorter wait time and, therefore, has decreased the need for a tourniquet. 12,13 As part of the protocol for this study, it was assured that all patients received their injection of local anesthetic plus epinephrine at least 30 minutes before the commencement of surgery. ...
... 12,13 Waiting for the maximal effect of epinephrine before the first incision has shown a threefold reduction in bleeding compared with a shorter wait time and, therefore, has decreased the need for a tourniquet. 12,13 As part of the protocol for this study, it was assured that all patients received their injection of local anesthetic plus epinephrine at least 30 minutes before the commencement of surgery. A major limitation of the recent systematic review published by Olaiya et al pertained to the preoperative preparation time, which is an important outcome for surgeons. ...
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Background: Carpal tunnel syndrome and trigger finger are two of the most common conditions treated by the hand surgeon. During these procedures, a tourniquet is often used to minimize bleeding and improve visualization of the operative field. However, it may be associated with pain and discomfort. To date, there are few prospective studies investigating the safety and patient-centered outcomes of tourniquet-free minor hand procedures. Methods: This is a randomized controlled trial comparing patients undergoing open carpal tunnel or trigger finger release with or without the use of a tourniquet. Perioperative subjective patient experience was investigated for both techniques. This was measured based on a numerical rating scale for pain, anxiety, and overall satisfaction. In addition, this was an equivalence trial in terms of operative time, bleeding scores, and perioperative complication rates. Results: A total of 67 patients were recruited. Both groups were similar with respect to distribution of age, sex, handedness, anti-platelet use, and tobacco use. Median scores for operative time, anxiety, and overall satisfaction were comparable between the 2 groups. With regard to patient discomfort, median scores were significantly higher in the tourniquet group when compared with the no tourniquet group (3.58 versus 1.68, respectively, P = 0.02). Bleeding scores for the tourniquet group were significantly lower than for the no tourniquet group (1.14 versus 1.90, respectively, P = 0.001). Conclusions: The application of wide awake local anesthesia no tourniquet (WALANT) in minor hand surgery procedures has been shown to decrease tourniquet-associated discomfort, improving perioperative patient experience. Additionally, it demonstrated the noninferiority of the tourniquet-free technique with respect to operative time and the rate of perioperative complications.
... Bleeding can be minimized with the WALANT technique by waiting for the optimal epinephrine effect after local anesthetic injection. Although vasoconstriction by epinephrine is traditionally believed to be optimal at approximately 7 to 10 minutes (min) from the time of injection [8], McKee et al. [8], in a prospective randomized trial, obtained the lowest cutaneous hemoglobin levels at roughly 26 min following injection of epinephrine. In their follow-up prospective comparative series [9] on carpal tunnel surgeries performed by WALANT, waiting roughly 30 min after injection of epinephrine resulted near three-fold reduction in mean quantity of intraoperative bleeding. ...
... Bleeding can be minimized with the WALANT technique by waiting for the optimal epinephrine effect after local anesthetic injection. Although vasoconstriction by epinephrine is traditionally believed to be optimal at approximately 7 to 10 minutes (min) from the time of injection [8], McKee et al. [8], in a prospective randomized trial, obtained the lowest cutaneous hemoglobin levels at roughly 26 min following injection of epinephrine. In their follow-up prospective comparative series [9] on carpal tunnel surgeries performed by WALANT, waiting roughly 30 min after injection of epinephrine resulted near three-fold reduction in mean quantity of intraoperative bleeding. ...
... irty-four patients were consecutively recruited from January 1 to December 31, 2019, with our sample size based on the calculation performed by McKee et al. [8] for their study. e patients were not formally randomized but allocated prior to arriving at the operating room, based on surgeon scheduling factors. ...
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Background: Additional studies on clinical outcomes to determine the optimal time delay from injection of local anesthesia to skin incision for WALANT surgeries are needed. The authors aimed to propose the optimal time delay from local injection to skin incision for WALANT surgeries of the hand and wrist by analyzing intraoperative blood loss, postoperative pain scores, and complication rates. Methods: Thirty-four patients were consecutively recruited and allocated by either 7-min or 30-min delay for skin incision from local injection of epinephrine with lidocaine. Intraoperative bleeding and postoperative pain scores were analyzed between both groups by Mann-Whitney U-test, while complication rates were compared using Fisher's exact test. Results: The present study did not find significant differences in mean intraoperative blood loss (8 ± 5.8 mL vs. 5 ± 2.2 mL, p=0.074), complication rates (18% vs. 0%, p=0.227), and mean pain scores (1.2 ± 0.5 vs. 1.4 ± 0.5, p=0.307) between the 7-min and 30-min groups. Conclusion: The authors conclude that a waiting time of 7 min from the injection of local anesthesia is sufficient to achieve comparable clinical outcomes for minor hand and wrist surgeries under WALANT.
... Moore et al. were able to show in their randomised, split-mouth, double-blind study that the application of 4% Articaine with epinephrine 1:100,000 resulted in less blood loss and a more bloodless surgical field than with 4% Articaine and epinephrine 1:200,000 [3].With regard to the vasoactive effect and the associated influence on the microcirculation, a subjective evaluation of the ischaemia-related colour change, colour doppler flow imaging, and pulse oximetry was carried out in most available studies [12]. However, there is an ongoing debate especially concerning the time to onset and duration of vasoconstriction with respect to the used drug combinations and dilutions [13]. Hyperspectral imaging (HSI) is a non-contact, non-ionising, and non-invasive technique that provides objective, reproducible, precise information about parameters used for tissue perfusion measurements and wound assessment [14][15][16]. ...
... Regarding the bloodlessness of the surgical field, there is controversy in the literature about the time interval required between injection and incision. While some authors consider less than 7 min sufficient [22,23], others recommend 13 [5] or even more than 25 min [13]. This could be due to different anatomical regions (eyelid versus forearm, neck, oral mucosa/gingiva), different concentrations of epinephrine or LA, too small case numbers as well as fundamentally different study protocols (e.g., close spacing of the injection sites in the eyelid area with result falsification as well as unsuitable drug combinations compared) and measurement methods (spectroscopy versus blood loss measurement). ...
Article
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This study aimed to investigate the dynamic skin perfusion via hyperspectral imaging (HSI) after application of Articaine-4% ± epinephrine as well as epinephrine only. After the subcutaneous injection of (A100) Articaine-4% with epinephrine 1:100,000, (A200) Articaine-4% with epinephrine 1:200,000, (Aw/o) Articaine-4% without epinephrine, and (EPI200) epinephrine 1:200,000, into the flexor side of the forearm in a split-arm design, dynamic skin perfusion measurement was performed over 120 min by determining tissue oxygen saturation (StO2) using HSI. After injection, all groups experienced a reactive hyperaemia. With A200, it took about three min for StO2 to drop below baseline. For Aw/o and EPI200, perfusion reduction when compared to baseline was seen at 30 min with vasoconstriction >120 min. A100 caused vasodilation with hyperaemia >60 min. After three minutes, the perfusion pattern differed significantly (p < 0.001) between all groups except Aw/o and EPI200. The vasoactive effect of epinephrine-containing local anaesthetics can be visualised and dynamically quantified via StO2 using HSI. Aw/o + epinephrine 1:100,000 and 1:200,000 leads to perfusion reduction and tissue ischaemia after 30 min, which lasts over 120 min with no significant difference between both formulations. When using Aw/o containing epinephrine in terms of haemostasis for surgical procedures, a prolonged waiting time before incision of 30 or more min can be recommended.
... The 14 min optimal interval for one-per-mil tumescent solution is relevant to the common practice of waiting 7-10 min after the last injection. If tumescent injection takes 10 min to act in a relatively large dissection area, incision should be performed at an interval of 17-20 min: i.e., longer than the usual interval [37]. Hernandez et al. found that the optimal waiting time was 7 min for WALANT hand and wrist surgery [38]. ...
... Slow injection of local anesthetics has the further advantage of allowing interactive communication between operator and patient, to minimize pain. Interestingly, in some surgeries the anesthetic effect of 0.2% lidocaine in one-per-mil solution outlasted the pharmacokinetic action duration; this may be due to differences in the anatomic location at which onset and action duration were studied in the finger pulp [19,37]. ...
Article
One-per-mil epinephrine solution (1:1,000,000) injected as a tumescent has been used in several hand and upper-limb surgery cases as a substitute for tourniquet. However, reviews of its effectiveness are still lacking. A comprehensive review was conducted based on PubMed, Scopus, Science Direct, Cochrane Library, and Semantic Scholar database search of relevant studies using the keyword “one-per-mil.” Studies not using the exact one-per-mil tumescent solution formula were excluded. The review of clinical studies was conducted according to PRISMA guidelines. Epinephrine and the hydrostatic vasocompressive effect created bloodless operative fields, with 100% experimental flap survival after ischemic insult. The technique was effective in creating bloodless operative fields in 36.3% of varied hand and upper-limb surgery cases and in fully awake surgery. Current studies show that one-per-mil tumescent solution is safe and effective, enabling use of tourniquet to be avoided.
... Epinephrine is often used in local anesthetics in plastic surgery to induce vasoconstriction in order to reduce bleeding and prolong anesthesia (McKee et al., 2013). The time taken to reach maximal hemostasis following the administration of epinephrine has recently become the subject of debate. ...
... The time commonly given in textbooks is 10 min (Collin and Rose, 2001). However, in a study by McKee et al., who measured the relative hemoglobin concentration over time in the arm skin of healthy volunteers using oxygen spectroscopy, at wavelengths of 300 to 1000 nm, the lowest cutaneous hemoglobin level was not observed until 26 min after injection (McKee et al., 2013). In another study, McKee et al. measured the blood loss from the skin of patients undergoing carpal tunnel release surgery, and found a significant reduction after 30 min, compared to 7 min (McKee et al., 2015). ...
Article
Background The aim of this study was to investigate the possibility of using extended-wavelength diffuse reflectance spectroscopy (EW-DRS) to measure tissue response related to blood perfusion. The study was performed on a model that we have previously found to be useful for studying techniques for perfusion monitoring following the injection of epinephrine in a local anesthetic in the human forearm. Methods Nine healthy subjects were included in the study. Spectroscopy was performed with an EW-DRS system using a combination of two spectrometers to resolve light in the visible (350 nm to 1100 nm) and the near-infrared regions (900 nm to 1700 nm). The change in signal upon the injection of lidocaine (20 mg/ml) + epinephrine (12.5 μg/ml) (LIDO +EPI), compared to a control injection with saline (9 mg/ml), was investigated. Results Injection of lidocaine + epinephrine (12.5 μg/ml) caused a change in the EW-DRS signal in the wavelength intervals 510 to 610 nm, known to change upon deoxygenation of hemoglobin. When examining the full wavelength range (450 to 1550 nm) a decrease in reflectance upon LIDO +EPI injection was observed, suggesting that the broader spectrum provides more detailed information on the tissue response. The time to stable hypoperfusion was found to be 2.6 min. Conclusions EW-DRS appears to be a promising technique for monitoring perfusion, and could provide a useful tool in plastic and reconstructive surgery. The broad spectrum provides detailed information on the molecular changes taking place in the tissue. However, the technique must be thoroughly validated before it can be implemented in clinical practice.
... [3][4][5] Waiting at least 26 minutes after injection and before cutting is important to achieve maximal vasoconstriction. 6 We waited 45 minutes in this case. There was no need for any additional local anesthesia injections during the procedure which took 70 minutes from incision to closure. ...
Article
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Wide awake, local anesthesia, no tourniquet hand surgery is a growing field of hand surgery with many advantages described in the literature. This technique is safely performed with the patient in prone position and offer several advantages.
... The most common concentration being used is 1:100,000 that has been reported to be safe and effective. 15,16 Regarding the time delay between injection of epinephrine solution and incision, McKee et al. 17 found that the optimal time delay to achieve maximum cutaneous vasoconstriction to yield optimal visualization is 25.7 min. On the other hand, some studies from South East Asia have come up with the effectiveness of much smaller concentration of epinephrine (1:1,000,000 or one-per-mil), which surprisingly reported to have waiting time before incision as 7-10 min 18,19 These data create a contradiction, in which a much smaller epinephrine concentration could still provide 7-10 min as optimum waiting time for incision. ...
Article
Background: This study aimed to find out the optimal time delay of epinephrine in one-per-mil tumescent solution containing 1:1,000,000 epinephrine and 0.2% lidocaine to achieve optimal visualization in hand surgery. Materials and methods: Twelve healthy male subjects who volunteered to join this prospective, randomized, double blind study were selected with convenient sampling technique. The subject's hand and the solution, either the one-per-mil or normal saline solution, were randomly selected. Injections were given to the ring finger's pulp, whereas the oxygen saturation (SpO2) of each finger was measured with Masimo's Radical-7 Pulse Oximeter at 5 min before injection and continuously up to 45 min after injection. The device showed the SpO2 every 2 s. Any value of SpO2 was noted if it stayed the same point for at least 30 s in a row without interruption. The time of the lowest SpO2 was recorded and analyzed. Results: The average of SpO2 after injection in the epinephrine group was 96.5 (95-97), P = 0.002, whereas the normal saline group was 97.5 ± 1.168, P = 0.003. Both were statistically significant compared with their respective baseline values. The average delta SpO2 of the epinephrine group was 3.42 ± 0.996, whereas the normal saline group was 1.50 ± 1.567 (P = 0.001; CI 0.923-2.911). The time to achieve the lowest SpO2 in the epinephrine group was obtained at the average time of 13.90 ± 5.38 min after injection. Conclusions: The optimal time delay of the epinephrine in the one-per-mil tumescent solution was 13.90 ± 5.38 min after injection.
... Approximately 10-15 ml of the local anaesthesia was injected into the operative site with a 25G about 20 to 30 minutes before the first incision for a good haemostatic effect. 14,15 The surgical site was sterilised and prepared for surgery, and preoperative intravenous 1.5g cefuroxime wasadministered to each patient as prophylaxis. The incision was made when the Visual Analogue Score (VAS) was 0. The volar approach was utilised for plating in all cases (Figure-2). ...
Article
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Objective: To evaluate the Wide-Awake Local Anaesthesia with No Tourniquet (WALANT) method in fixation of distal radial fractures. Methods: Forty patients admitted to the Jinnah Postgraduate Medical Centre, Karachi, Pakistan were recruited from March 2017 to December 2018. All patients had a distal radial fracture which was appropriate for internal fixation with a locked volar distal radial plate. The surgical site was infiltrated to achieve tumescent local anaesthesia using a solution of 0.9% normal saline and 1% lidocaine with 1:1,000,000 epinephrine. The patients were followed up until fracture union and were evaluated clinically, with goniometry, radiologically and with standard outcome scores (Mayo and qDASH). Results: The patients were marginally more male than female (55% versus 45%), and mostly the dominant hand was injured (65%). The mean time to union was just over 3 months (15.2 weeks). All were united by 11 months. Good outcomes were achieved at final review with mean qDASH and Mayo scores of 13.3 and 81.6 respectively. The mean flexion and extension range at finalreview was 64 and 53 degrees respectively, and the mean grip strength was 73% when compared with the opposite side. Conclusions: The WALANT technique seems to be an acceptable and safe technique for fixation of distal radial fractures. There seem to be added benefits in terms of costs, reduced disposables, and intra-operative assessment of active movement.
... McKee et al. recommended adrenaline injection to be given at least 26 min prior to the surgery for optimal vasoconstriction. 21 The preparation time (mixing WALANT components) was just marginally longer by 1 or 2 min (where we added one vial of lignocaine and dilute it with normal saline), and the injection was given about 30 min in the treatment room prior to operation theatre (OT) arrangements (attire changing namely), thus saving time while waiting for optimal vasoconstriction. We certainly found it more convenient to give all the WALANT injections all at once very early on before commencement of the day-care list as we spend time communicating gently with the patients and reducing any fear and anxiety in a relaxed section of the day-care area rather than injecting local anesthesia on the operating table when patients are more anxious. ...
Article
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Background: Trigger finger release utilizing wide-awake local anesthesia no tourniquet (WALANT) usage in extremity surgery is not widely used in our setting due to the possibility of necrosis. Usage of a tourniquet is generally acceptable for providing surgical field hemostasis. We evaluate hemostasis score, surgical field visibility, onset and duration of anesthesia, pain score, and the duration of surgery and potential side effects of WALANT. Methods: Eighty-six patients scheduled for trigger finger release between July 2016 and December 2017 were randomized into a control group (1% lignocaine and 8.4% sodium bicarbonate with arm tourniquet; given 10 min prior to procedure) and an intervention group (1% lignocaine, 1:100,000 of adrenaline and 8.4% sodium bicarbonate; given 30 min prior to procedure), with a total of 4 ml of solution injected around the A1 pulley. The onset of anesthesia and pain score upon injection of the first 1 ml were recorded. After the procedure, the surgeon rated for the hemostasis score (1-10: 1 as no bleeding and 10 being profuse bleeding). Duration of surgery and return of sensation were recorded. Results: Hemostasis score was grouped into visibility score as 1-3: good, 4-6: moderate, and 7-10: poor. The intervention group (with adrenaline) had a 74% of good surgical field visibility compared to 44% from the controlled group (without adrenaline; p < 0.05). Duration of anesthesia was longer in the intervention group (with adrenaline), with a 2.77-h difference. Conclusion: WALANT provides excellent surgical field visibility and is safe and on par with conventional methods but without the usage of a tourniquet and its associated discomfort.
... Though epinephrine's maximal effect on arterial vasoconstriction may work at 7 to 10 min, it takes considerably longer for a new local equilibrium to be obtained with regard to hemoglobin quantity. If optimal visualization and fixation are desired, the ideal time for cement hardening should be the time when local hemoglobin concentration is lowest [24,25]. Therefore, it is sufficient for fully cementing all areas of contact of the tibia and femur by preparing cement, applying it to both the bone and the component surfaces, then holding components carefully in place until the cement has completely polymerized. ...
Article
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Background: Reducing tourniquet inflation time is important because of the complications of tourniquet extensively used for the control of hemorrhage in total knee arthroplasty (TKA). Bleeding management is critical to acquire a relative bloodless arthrotomy interface for maximize cement fixation in non-tourniquet TKA. The purpose of this study was to investigate hemostatic and hemodynamic effects of epinephrine-soaked gauzes in cemented TKAs. Methods: A retrospective cohort study of 101 patients in two groups was performed. The first group (n = 51) underwent unilateral TKA with our procedures of epinephrine use, the second group (n = 50) had the same protocol with tourniquet and no epinephrine utilization. Surgical field visualization was assessed by grading scale for difficulty of intraoperative visualization due to blood and number of surgical field clearances. Perioperative blood loss was recorded. Hemodynamic parameters were observed in the epinephrine group. Results: There was statistically significant difference (p < 0.01) on surgeon-rated difficulty in visualization in the epinephrine group between before and after use of epinephrine, and no statistically significant difference (p = 0.96) between two groups before cementing. No statistically significant result on numbers of surgical field clearances between two groups (p = 0.25) was found. Epinephrine group showed significant difference in hidden blood loss compared with no epinephrine group (576.6 ± 229.3 vs 693.2 ± 302.9, respectively, p = 0.04). The hemodynamic effects of epinephrine may be under control. Conclusion: The procedure of epinephrine soaked gauzes, as a prudent adjunct, may be effective to reduce blood loss and obtain bloodless bone sections in non-tourniquet TKAs, regardless of hemodynamics.
... Each EMW band has an exposure threshold or 'minimal erythema dose' (MED) [6]; if reached, skin erythema is directly induced [7]. In addition to EMW exposure, physical pressure [8], skin ulceration [9,10], application of cosmetic and medical topical agents, and electrical stimulation [11][12][13][14] are all external stimuli of skin erythema. Over and above, burns induce erythema around resultant scars [15]. ...
Article
Abstract Background Skin erythema may present due to many causes. One of the common causes is prolonged exposure to sun rays. Other than sun exposure, skin erythema is an accompanying sign of dermatological diseases such as acne, psoriasis, melasma, post inflammatory hyperpigmentation, fever, as well as exposure to specific electromagnetic wave bands. Methods Quantifying skin erythema in patients enables the dermatologist to assess the patient’s skin health. Therefore, quantitative assessment of skin erythema was the target of several studies. The clinical standard for erythema evaluation is visual assessment. However, the former standard has some imperfections. For instance, it is subjective, and unqualified for precise color information exchange. To overcome these shortcomings, the past three decades witnessed various methodologies that aimed to achieve erythema objective assessment, such as diffuse reflectance spectroscopy (DRS), and both optical and non-optical systems. Discussion This review article revises the studies published in the past three decades where the performance, the mathematical tactics for computation, and the limited capabilities of erythema assessment techniques for cutaneous diseases are discussed. In particular, the current achievements and limitations of the current techniques in erythema assessment are presented. Conclusion The profits and development trends of optical and non-optical methods are displayed to provide the researcher with awareness into the present technological advances and its potential for dermatological diseases research. Keywords Skin pigments; Erythema assessment; Dermatological diseases; Skin inflammation; Optical diagnosis
... Растворы местных анестетиков, используемые для инфильтрации мягких тканей в пластической хирургии, как правило, содержат различные концентрации адреналина, добавляемого с целью уменьшения кровоточивости тканей, замедления абсорбции и пролонгации эффекта. После подкожного введения адреналина необходимо 26 мин для развития его максимального вазоконстрикторного эффекта, а не 7 мин, как полагали ранее [33]. Несоблюдение временного интервала 26 мин приводит к значительной кровоточивости операционного поля после разреза кожи. ...
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The review is devoted to the questions of prophylaxis and treatment of postoperative pain in plastic surgery. The pain in plastic surgery remains a serious problem in particular after major reconstructive-reparative operations. It impedes patient timely discharge from hospital in same-day surgery. Postoperative pain in plastic surgery may become chronic in 10-40% cases especially after operations on mammary glands. The basis of postoperative analgesia in plastic surgery is combined using of nonopioid analgesics (NSAIDs, paracetamol, gabapentin) and different variants of regional analgesia. Opioid analgesics are considered as reserve drugs for cases when nonopioid analgesia isn't effective.
... The surgical procedures lasted less (in both groups 12 minutes) than the time it takes for the maximum vasoconstrictive effect of epinephrine to occur (25 minutes after injection of local anesthetic with epinephrine). 25 For that reason, we expected that the increased blood flow after the release of the tourniquet would lead to more hematoma and subsequently to more scar formation in the tourniquet group compared with the no-tourniquet group. The formation of postoperative scar tissue around the nerve was determined by ultrasound, which is less invasive and less expensive than magnetic resonance imaging. ...
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Background:. Surgeons often prefer to use a tourniquet during minor procedures, such as carpal tunnel release (CTR) or trigger finger release (TFR). Besides the possible discomfort for the patient, the effect of tourniquet use on long-term results and complications is unknown. Our primary aim was to compare the patient-reported outcomes 1 year after CTR or TFR under local anesthesia with or without tourniquet. Secondary outcomes included satisfaction, sonographically estimated scar tissue thickness after CTR‚ and postoperative complications. Methods:. Between May 2019 and May 2020, 163 patients planned for open CTR or TFR under local anesthesia were included. Before surgery, and at 3, 6, and 12 months postoperatively, Quick Disabilities of the Arm, Shoulder and Hand and Boston Carpal Tunnel questionnaires were administered, and complications were noted. At 6 months postoperatively, an ultrasound was conducted to determine the thickness of scar tissue in the region of median nerve. Results:. A total of 142 patients (51 men [38%]) were included. The Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Boston Carpal Tunnel Questionnaire scores improved significantly in both groups during follow-up, wherein most improvements were seen in the first 3 months. No difference in clinical outcome and scar tissue formation was found between the two groups after 12 months. The complication rate was comparable between both groups. Thirty-two (24%) patients had at least one complication, none needed surgical interventions, and no recurrent symptoms were seen. Conclusions:. Our study shows similar long-term clinical outcomes, formation of scar tissue, and complication rates for patients undergoing CTR or TFR with or without a tourniquet. Tourniquet usage should be based on shared decision-making.
... We have found the technique endorsed by Lalonde, mixing 1:100,000 adrenaline with 1% lidocaine, gives optimum haemostatic effect for the repair of flexor tendons at all levels of injury. This concentration is safe, widely adopted in the literature, and enhanced by waiting 25 minutes before the first surgical incision [5]. ...
... A stab incision was performed 2-3 cm below the inferior margin of the areola. With a standard infiltration cannula 3 mm in diameter and 20 cm in length, 100 cc solution infiltration was performed to each breast in Group 2, and 500 cc solution infiltration was performed to each breast in Group 3. The vasoconstriction effect of adrenaline was waited for 15-20 minutes following the infiltration, and then, the operation was started [14]. In patients undergoing open surgery only, incision of a semilunar shape was made from the lower ½ of the nippleareola complex, and the breast gland and adipose tissues were excised. ...
Article
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Objectives: Bleeding is an important problem in the surgical treatment of gynecomastia. The most implemented method to decrease the amount of bleeding is adrenaline infiltration, but adrenalin is mostly infiltrated with the fluid in the volume less than 250 cc in the clinic. It is expected that adrenaline will accumulate more in the tissue and thus, exhibit more bleeding-reducing effect by increasing the fluid volume used in the infiltration. In this study, the aim is to reveal the effect of increasing the amount of adrenaline in tissues by infiltrating a higher-volume solution without increasing the adrenaline concentration in patients who have received gynecomastia treatment by an open surgery on the postoperative blood loss and surgical complications in patients. Materials and Methods: Patients who had undergone open gynecomastia surgery between 2011 and 2017 were retrospectively examined. Patients not subjected to infiltration were described as Group 1 (n:9), patients infiltrated with adrenalin 100 cc were described as Group 2 (n:13), and patients infiltrated with adrenalin 500 cc were described as Group 3 (n:23). Results: The average decrease in the hemoglobin level (bleeding) after the operation was calculated to be 2.00±0.37 in Group 1, 1.5±0.4 in Group 2, 0.7±0.30 in Group 3 and the differences between groups were statistically significant (p<0.001). Conclusion: The infiltration of adrenaline in the same concentration with a fluid of a higher volume decreases blood loss after the gynecomastia surgery operation.
... Though epinephrine's maximal effect on arterial vasoconstriction may work at 7 to 10 minutes, it takes considerably longer for a new local equilibrium to be obtained with regard to hemoglobin quantity. If optimal visualization and fixation are desired, the ideal time for cement hardening should be the time when local hemoglobin concentration is lowest [20,21]. Therefore, it is sufficient for cementing of the tibia and femur by preparing two batches of cement 6 to 9 minutes apart, then holding components carefully in place until the cement has completely polymerized. ...
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Background Abandoning tourniquet was commenced because of the complications of tourniquet extensively used for the control of hemorrhage in total knee arthroplasty (TKA). Bleeding management is critical to acquire a relative bloodless arthrotomy interface for maximize cement fixation in non-tourniquet TKA. The purpose of this study was to investigate hemostatic and hemodynamic effects of epinephrine-soaked gauzes in cemented TKAs. Methods A retrospective cohort study of 101 patients in two groups was performed. The first group (n = 51) underwent unilateral TKA with our procedures of epinephrine use, the second group (n = 50) had the same protocol with tourniquet and no epinephrine utilization. Surgical field visualization was assessed by grading scale for difficulty of intraoperative visualization due to blood and number of surgical field clearances. Perioperative blood loss were recorded. Hemodynamic parameters were observed in the epinephrine group. Results There was statistically significant difference (p < 0.01) on surgeon-rated difficulty in visualization in the epinephrine group between before and after use of epinephrine, and no statistically significant differences (p = 0.96) between two groups before cementing. No statistically significantly result on numbers of surgical field clearances between two groups (p = 0.25) was reached. Significant difference in hidden blood loss, was observed in two groups (p = 0.04). The hemodynamic effects of epinephrine may be under control. Conclusion The procedure of epinephrine soaked gauzes, as a prudent adjunct, may be effective to reduce blood loss and obtain bloodless bone sections in non-tourniquet TKAs, regardless of hemodynamics.
... In our cohort, excessive intraoperative bleeding was not a common occurrence. As described by McKee et al, 9 delaying the procedure by 25e30 minutes after epinephrine administration minimized bleeding and provided adequate hemostasis. Gauze may also be inserted into the canal to wick away bleeding and permits the surgeon to continue the operation safely with adequate visualization. ...
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Carpal tunnel syndrome is the most common upper extremity peripheral neuropathy syndrome. Treatment ranges from nonsurgical methods, including night-orthosis fabrication and corticosteroid injections to surgical management via a carpal tunnel release (CTR). Carpal tunnel release alleviates nerve compression by releasing the transverse carpal ligament, and performed as either an open CTR (OCTR) or endoscopic CTR (ECTR) procedure. However, there is no consensus on the superiority of the 2 approaches. Practitioners may be limited to 1 technique because of surgeons’ comfort, access to an operating room versus a procedure room, and cost. The purpose of this article was to describe the surgical technique for wide awake, local anesthesia, no tourniquet ECTR performed in an office-based setting, which would decrease operating room demand and cost.
... 8 Furthermore, the mean operation time of these patients was significantly longer (98.3 minutes) than that of the 143 patients who did not require tourniquet use (39.8 minutes) (Fig. 3). 8 McKee et al 13 reported that the greatest hemostatic effect is obtained 25 minutes after epinephrine injection. 14 Five out of 148 patients required tourniquet use for bleeding control. ...
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As a recent advance in the field of hand surgery, the wide-awake local anesthesia no tourniquet surgical technique—performed using an epinephrine-containing local anesthetic without a tourniquet while the patient is awake—has attracted attention. The wide-awake local anesthesia no tourniquet technique has been indicated for surgeries such as trigger release, soft tissue tumor excision, surgery for Dupuytren contracture, thumb carpometacarpal arthroplasty, or any other tendon, nerve, or ligament surgeries, requiring intraoperative active motion confirmation. Herein, the surgical procedures performed with the wide-awake local anesthesia no tourniquet technique have been described; moreover, the indications and precautions of this technique have been reconsidered.
... a At each dot, 10 mL of the WALANT solution was injected at different angles into the volar (4 mL), lateral (2 mL) and posterior (4 mL) aspects of the radius within the periosteal layer. (23,24) proposed waiting approximately 30 min after administering the injection to maximize hemostasis before making an incision. The widely accepted maximal dose of lidocaine that is believed to be safe for upper extremity surgery is 7 mg/kg (25). ...
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Background Distal radius fractures are treated using open reduction and internal fixation and using general anesthesia (GA) or regional blocks. A new technique, wide-awake local anesthesia with no tourniquet (WALANT), allows this operation to be conducted in nonsedated patients without the use of tourniquets.Objective We analyzed whether WALANT yields better outcomes than GA in the treatment of patients with distal radius fractures.Evidence ReviewWe searched the PubMed, Cochrane Library, Embase, and Scopus databases for cases of distal radius fractures treated using WALANT or GA. The outcomes of interest were duration of preparation for surgery, duration of surgery, blood loss, and length of postoperative hospitalization; visual analog scale (VAS), Mayo wrist score, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire score on postoperative day 1; range of motion (ROM); time until bone union; and complication rate.FindingsWe systematically reviewed 4 studies with a total of 263 patients (128 with WALANT and 135 with GA). In comparison with GA, WALANT required less time for preparation for surgery, shorter postoperative hospitalization, and lower postoperative day 1 VAS scores; however, blood loss was greater. Functional outcomes (ROM, QuickDASH score, and Mayo wrist score), complication rates, and times until union did not differ considerably between the two methods.Conclusion The included studies demonstrated that durations of preparation for surgery and postoperative hospitalization were shorter and pain on postoperative day 1 was less severe with WALANT than with GA. Although blood loss in surgery was greater with WALANT, this technique is a novel and promising alternative to GA.
... Patients in the WALANT group received the cocktail solution in the preparation room about 30 min before surgery since it takes approximately 26 min to allow for maximal vasoconstrictive effects of epinephrine. 11 The patients were monitored by the assigned nurse while waiting in the preparation room in case of emergencies, including digital ischemia, allergic reaction, and falling accident. Five minutes before surgery, the patients were brought into the operation room for surgery. ...
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Purpose: Hemostasis and local anesthetic injection are essential for minor hand surgeries under local anesthesia (LA). Wide awake local anesthesia no tourniquet (WALANT) became popular for achieving hemostasis without a tourniquet. However, a recent study reported that injection is more painful than tourniquet use in minor hand surgery. Therefore, this study aimed to compare three LA methods that differ according to injection and hemostasis, namely, the combination of a tourniquet and buffered lidocaine solution (CTB), WALANT, and conventional LA. Methods: This randomized prospective single-center study included 169 patients who underwent minor hand surgery between 2017 and 2020. We randomly allocated the patients to each group and recorded the pain and anxiety score during the surgery, as well as satisfaction after the surgery. Results: Pure lidocaine injection was significantly more painful than buffered lidocaine and WALANT solution injection ( p < 0.001). Local anesthesia injection was significantly more painful than tourniquet use in all groups ( p < 0.001). The intraoperative anxiety score was significantly lower in the CTB group than in the conventional LA and WALANT groups ( p < 0.001). The satisfaction score was significantly higher in the CTB and WALANT groups than in the conventional LA group ( p < 0.001). Conclusion: CTB for minor hand surgery under LA is associated with less injection pain and patient anxiety. The tourniquet is tolerable without much pain and waiting time. Thus, CTB in minor hand surgery is a good alternative to WALANT and conventional LA.
... A total of 10cc of local anesthesia were used for this combined anesthesia. The surgery was performed 20 min after injecting the anesthetic solution (Figure 1) [15]. ...
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Aim Evaluating patient comfort during full awake local anesthesia in carpal tunnel release surgery, without tourniquet use, by using epinephrine to obtain a completely dry surgical field. Methods We included into the study 41 patients who underwent carpal tunnel syndrome surgery under full awake combined anesthesia, using a 9-point questionnaire. Pain and anxiety in all patients were evaluated through a Wang-Baker 0-5 scale. The injection solution consisted of 0.1cc of epinephrine and 10cc of 1% lidocaine (1:100.000); 5cc were used for local cutaneous anesthesia, and 5cc were used for distal median nerve block. All patients underwent a classic, open carpal tunnel release. Results Anxiety scores during anesthesia and the post-operative period did not show a statistically significant difference (p>0.01), with keeping their levels at low perception scores (average score of 1.68±0.38 CI 95%, with a modal value of 2, compared to an average of 0.78±0.29 CI 95% with a modal value of 0). Similar results were obtained for pain scores during anesthesia (1.73±0.48 CI 95% with a most frequent modal score of 1). Our results also showed that the effects of combined anesthesia in carpal tunnel release surgery persisted well into the 6-hour post-operative moment, pain scores remaining low, statistically significant similar to recorded values during the anesthesia moment (p>0.01), at an average of 2.29±0.5 CI 95% with a modal value of 1. No serious complications were recorded. Conclusion Combined distal median nerve block and local anesthesia with epinephrine:lidocaine provides a comfortable option for patients, with minimal risks of complications.
Article
Wide awake local anesthesia no tourniquet (WALANT) refers to an anesthesia technique with low bleeding and complication rates, which enables interventions on the hand in an awake patient without the use of a tourniquet. Bleeding control is achieved through addition of vasoconstrictors to the infiltration solution. Since the motor function of the extremity is not affected, it offers the additional possibility of intraoperative active function testing. The WALANT procedure constitutes an established, effective, easily learnt and resource-sparing technique. The spectrum of surgical possibilities with WALANT is wide and covers nearly all elective and many emergency procedures. Due to multiple advantages in contrast to other regional and general anesthesia procedures, WALANT features an increasing spectrum of surgical applications and practitioners. It is therefore of interest for hand surgeons working both in hospitals and private practices.
Article
Despite the introduction of various techniques for ligament reconstruction in the treatment of thumb carpometacarpal (CMC) arthritis, complications, including proximal migration, dorsal subluxation of the first metacarpal base, hyperextension of the thumb metacarpophalangeal joint, and impingement between the first and second metacarpal bases, have been reported. Even suture button suspensionplasty with Arthrex Mini TightRope may be unable to correct the adduction contracture deformity and does not effectively tether the trapeziometacarpal toward the base of the index metacarpal, thus potentially leaving patients with persistent decreased first web space angle, proximal migration, and collapse deformity. Hence, suture suspension arthroplasty with abductor pollicis longus (APL)-flexor carpi radialis (FCR) tendon suture after trapeziectomy, a simpler technique, was applied. This simple surgical reconstruction abducts the first metacarpal bone. Abduction of the CMC joint improves metacarpophalangeal joint hyperextension. However, strong tension of the APL-FCR causes abduction contracture of the first CMC joint and difficulty of pinch motion of the thumb to the other fingers. Therefore, we have modified the arthroplasty with a wide-awake approach. The procedure is performed with the patient fully awake under local anesthesia, without a tourniquet to allow the patient to actively move and pinch the thumb, which allows the surgeon to confirm the tension of the APL-FCR suture. A fiber wire is connected to the APL-FCR with proper tension. The patient and surgeon can ensure pinch motion and thumb opposition with satisfaction during surgery.
Article
This article summarizes the application of local anesthesia no tourniquet in 2 hand surgery centers in China, Nantong and Tianjin, where more than 12,000 patients were operated on with the new approach. This approach achieves excellent anesthetic and vasoconstrictive effects. In Nantong, surgeons performed fracture fixation, soft tissue tumor excision, and flap transfer in the hand with this approach. In Tianjin, surgeons applied it to cases of hand trauma emergency surgery. The authors’ experience shows that this approach to hand surgery is safe, economical, and patient friendly, with no increase in infection rate.
Article
The wide awake anesthesia technique is a useful tool in secondary tendon reconstruction. With active participation of the patient, the tendon repair can be adjusted appropriately to prevent repairs that are too tight or too loose. Areas of tendon scarring or triggering can be identified and released. Other advantages of active participation include reduction of gapping, ensuring adequate strength of repair, and avoiding tendon imbalances. Last, it allows intraoperative patient education and may therefore increase patient satisfaction. This article discusses how the technique can be applied to tenolysis, 2-stage tendon reconstruction, and tendon transfer.
Article
Background The management of severe burn-injured Jehovah’s Witness patients who decline a blood transfusion poses unique challenges. There is a paucity of literature guiding perioperative anaemia management in these patients. We present a systematic review of this patient group, along with illustrative, consecutive case reports of our experience. Methods A systematic review was performed on Embase, MEDLINE and PubMed databases on articles discussing the treatment of burn-injured Jehovah’s witness patients. Articles were excluded if discussing isolated inhalation injury, or if blood transfusions were permitted. Results 9 articles including a total of 11 patients revealed consistent themes. A multimodal medical and surgical approach is suggested. Medical strategies are directed at reducing blood loss and optimising haematopoiesis and include rationalising blood collection, reversing coagulopathy, administering tranexamic acid and regular erythropoietin. Surgical strategies include staged aggressive debridement, tumescent adrenaline infiltration and limb tourniquets. We found that the argon beam coagulator was an effective haemostatic adjunct not previously described in literature. Discussion Management of anaemia in severely burn-injured Jehovah’s witness patients is challenging. This systematic review presents a summary of strategies directed at minimising blood loss, and optimising haematopoiesis. Careful preoperative planning, meticulous surgical technique, and postoperative physiological support are caveats to success.
Article
Most unstable metacarpal and phalangeal fractures for which operative treatment is indicated can be reduced and stabilized with either open or closed techniques using local anesthetic with epinephrine instead of intravenous sedation or general anesthesia. With the patient wide-awake during surgery, the hand can be taken through active range of motion to assess fracture stability. In this article, the authors review the rationale and technique for wide-awake, local anesthesia, no tourniquet surgery in the treatment of phalangeal and metacarpal fractures and impart pearls to optimize the patient experience and illustrate common fixation techniques using percutaneous Kirschner wires. The intraoperative assessment of fracture stability permits an accelerated, protected-range-of-motion protocol that minimizes postoperative stiffness and facilitates expedient recovery.
Article
Resumo As fraturas do escafoide representam entre 50 e 70% de todas as fraturas dos ossos do carpo. A osteossíntese percutânea do escafoide pode usar a abordagem dorsal ou volar, ambas com bons resultados. É mais comumente realizada sob anestesia geral ou bloqueio nervoso regional. A técnica de anestesia local com o paciente totalmente acordado e sem torniquete (WALANT, na sigla em inglês) já é considerada uma técnica segura e eficaz na cirurgia da mão. A anestesia local com epinefrina causa vasoconstrição, o que evita o uso de torniquete e, consequentemente, a necessidade de sedação do paciente. Assim, a possibilidade de testar a estabilidade da fixação sob forças fisiológicas é outra grande vantagem do uso da anestesia local. Na técnica descrita aqui, o movimento ativo do punho e da mão pode ser testado imediatamente após a fixação escafoide. A técnica WALANT tem sido cada vez mais utilizada na cirurgia da mão em partes moles e na fixação de fraturas de metacarpo e falanges. No entanto, até o momento, não há literatura publicada abordando o uso dessa técnica na osteossíntese percutânea do escafoide. O objetivo desta nota técnica é descrever o uso de WALANT tanto para a abordagem dorsal quanto volar na osteossíntese percutânea do escafoide.
Article
Purpose: Epinephrine is used in local anesthetics to induce vasoconstriction and thus reduce bleeding and prolong the anesthetic effect. Finding the optimal delay between the administration of the anesthetic and skin incision to ensure vasoconstriction and minimize bleeding is important and has recently become the subject of debate. This is the first study to assess blood perfusion and oxygen saturation (sO2) simultaneously in response to a local anesthetic containing epinephrine in human oculoplastic surgery. Methods: A local anesthetic consisting of lidocaine and epinephrine (20 mg/ml + 12.5 μg/ml) was injected in the eyelids of 9 subjects undergoing blepharoplasty. The perfusion and sO2 of the eyelids were monitored using laser speckle contrast imaging and hyperspectral imaging, respectively. Results: Laser speckle contrast imaging monitoring showed a decrease in perfusion over time centrally at the site of injection. Half-maximum effect was reached after 34 seconds, and full effect after 115 seconds, determined by exponential fitting. The drop in perfusion decreased gradually further away from the injection site and hypoperfusion was less prominent 4 mm from the injection site, with a spatially dependent half-maximum effect of 231 seconds. Hyperspectral imaging showed only a slight decrease in sO2 of 11 % at the injection site. Conclusions: The optimal time delay for skin incision in oculoplastic surgery is approximately 2 minutes after the injection of lidocaine with epinephrine. Longer delay does not lead to a further decrease in perfusion. As sO2 was only slightly reduced after injection, the results indicate that the use of epinephrine is safe in the periocular region.
Article
The management of phalangeal and metacarpal fractures continues to evolve. Nonoperative or less invasive techniques, limiting the need for soft tissue dissection and resultant stiffness, are being developed and becoming more popular. The competing forces of fracture stability to optimize healing and early mobilization to optimize function need careful balancing. As imaging, equipment, and techniques improve, hand surgeons can tailor individualized care to the unique needs of each patient.
Chapter
The dermatologic indications for local and regional infiltrated anesthesia are abundant. Local infiltrative anesthesia is considered safe and effective for an array of procedures including excisions, biopsies, wound closures, skin grafting, cauterization, nonablative laser, and ablative skin resurfacing. Few contraindications to local and regional infiltrated anesthesia exist but should be screened for during the preoperative consultation. Numerous techniques for achieving adequate local and regional anesthesia have been described, including practices to lessen the pain associated with injection. Common side effects of local infiltrative anesthesia include pain, erythema, edema, bleeding, and ecchymoses. While overall well tolerated and commonly used, local and regional infiltrative anesthetic procedures do carry risks for toxicity and death. A comprehensive understanding of the pathophysiology, technique, and potential adverse events of various local and regional infiltrated anesthetics is critical to improve patient satisfaction and safety.
Article
Resumen Objetivo Evaluar los beneficios para el paciente y el impacto económico de la implantación de un circuito de cirugía con anestesia local sin manguito ni sedación (wide awake local anesthesia no tourniquet technique [WALANT], por sus siglas en inglés) comparado con pacientes intervenidos en quirófano con cirugía mayor ambulatoria. Método Se diseñó un estudio de cohortes prospectivo comparando 150 casos intervenidos (túneles carpianos y dedo en resorte) de forma ambulatoria mediante técnica WALANT con otros 150 pacientes operados en circuito de cirugía mayor ambulatoria, con evaluación preoperatoria, anestesia regional y torniquete, en quirófano convencional. El dolor pre-, intra- y postoperatorio fue monitorizado, así como los días que precisaron de analgesia postoperatoria. Se evaluaron los costos y recursos utilizados. El grado de satisfacción del paciente fue evaluado mediante un formulario específico. Resultados El dolor intraoperatorio fue similar en ambos grupos, hallando diferencias significativas en cuanto a la necesidad de analgesia postoperatoria a favor del grupo WALANT. El grado de satisfacción fue mayor para el grupo de anestesia local. La utilización de recursos materiales y de personal fue menor en WALANT, calculando un ahorro por paciente de 1,019 €. Conclusiones Cirugías como el túnel carpiano y el dedo en resorte pueden llevarse a cabo de forma segura mediante la técnica WALANT. La satisfacción del paciente es mayor que la de los pacientes intervenidos en el quirófano. El control del dolor es excelente, especialmente durante el postoperatorio. La técnica WALANT reporta un beneficio para el paciente en términos de bienestar y rapidez, además de permitir prescindir de pruebas y visita preoperatorias. Su implantación supone un ahorro significativo de recursos hospitalarios.
Article
Introduction: Hand and wrist surgeries are often carried out under local/regional anesthesia. We describe our experience using Surgeon Administered Local/Regional Anaesthesia (SALoRA) without sedation to deliver acute and elective hand surgery anesthesia in a tertiary public hospital in Singapore. This is in comparison to wide awake local anesthesia no tourniquet, which has been increasing in popularity. Methods: Retrospective analysis was conducted on all surgeries performed under SALoRA between January 1, 2013, to December 31, 2016, at our institution. Surgeries on areas other than the hand, wrist, forearm, and elbow were excluded. The records were reviewed to analyze the demographics of the patients, profile of cases performed, and their outcomes. Results: Of a total of 3016 cases performed, 1994 patients (1275 men; age, 45.78 ± 16 years) fulfilled the inclusion criteria and were available for analysis for the study period. The case distribution was similar to most other published data on day hand surgery cases. Tourniquet was used in 1357 (68%) of cases with an average operation time of 26 ± 19 minutes. Mean tourniquet use was 24 ± 15 minutes. Detailed analysis will be presented. Conclusion: This study shows the versatility of SALoRA in delivering hand surgery in a cost-effective manner. A wide spectrum of surgeries in the hand, wrist, forearm, and elbow can be performed using SALoRA safely. This has increased productivity, efficiency, and use of resources. SALoRA has the advantage of a guaranteed and reliable bloodless field, quick turnaround time without the need of extra personnel and resources needed for patient monitoring to abide by Joint Commission International requirements and the potential risk of systemic adrenaline effects.
Article
Hypothesis To evaluate benefits for the patient and the economic impact for the implementation of a wide awake local anesthesia no tourniquet (WALANT) hand surgery compared to traditional major outpatient circuit. Methods A prospective cohort study was planned comparing 150 cases of ambulatory hand surgery (carpal tunnel and trigger finger) using WALANT technique intervention out from the operating room; with another 150 which underwent intervention, outpatient setting, with preoperative evaluation, sedation and tourniquet, in the operation room (OR). Preoperative, intraoperative and postoperative pain was monitored, as well as the use of analgesics after the surgery. The resources used and costs were evaluated. Satisfaction was evaluated using a specific survey. Results The pain during the surgery was equivalent for both groups and was significantly lower postoperatively for the WALANT group, with less need for the use of analgesics. Satisfaction was greater for the local anesthesia group. The use of personnel resources and hospital material was less for the WALANT group, with total saving calculated by 1,019€ per patient. Summary Procedures such as carpal tunnel surgery and trigger finger surgery can be safely performed using wide awake surgery. Patient satisfaction is higher to conventional procedure in the OR. Pain control is excellent, especially during the postoperative period. WALANT technique for hand surgery represents a benefit for the patient in comfort, timeliness and no need for a preoperative evaluation or blood test. In addition, it represents a significant savings in hospital resources.
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Purpose: This study aimed to compare the efficacy of and patient satisfaction with the wide-awake local anesthesia with no tourniquet (WALANT) technique in open cubital and carpal tunnel release surgery. Methods: From January 2016 to February 2017, 20 cubital tunnel syndrome (CuTS) patients were in a wide-awake (WA) group and 22 in a general (GA) anesthesia group in . Also, 20 carpal tunnel syndrome (CTS) patients were in a WA group, 22 in a local anesthesia (LA) group, and 20 in a GA group. Injection pain, perioperative pain, and postoperative pain were assessed using a 10-point pain VAS. In CuTS, functional outcome on the "quick" Disabilities of the Arm, Shoulder, and Hand questionnaire were evaluated. In CTS, subjective outcomes were assessed using the Korean version of the Michigan Hand Outcomes Questionnaire. Results: Both CuTS and CTS showed significant postoperative pain reduction in group WA. In CuTS, group WA had less pain than group GA up to 48 hours after surgery (P<0.05). Supplemental opioid injections were used on hospitalization day by 12% of group WA and 35% of group GA. In CTS, the postoperative VAS scores in group WA were lower during the first 24 hours than groups LA and GA (P<0.05). Opioid injections were used on hospitalization day by 5% of WA, 18% of LA, and 32% of group GA. There was no difference in postoperative functional outcomes according to anesthesia method in CuTS or CTS. Conclusion: Cubital and carpal tunnel surgery using the WALANT technique was comparable in function to other anesthesia methods and superior for pain. Immediate postoperative pain was much lower than other groups, which could reduce the use of opioids during hospitalization.
Chapter
The overwhelming majority of skin cancer surgery is accomplished with local anesthesia, which accounts for some of the safety and cost-effectiveness benefits of clinic-based dermatologic surgery vs. procedures conducted in hospital operating rooms. Pain control is one of the most important components of skin cancer surgery. When done well, it makes the surgical experience much more pleasant for both the patient and the surgeon. Pain control for outpatient procedures requires a holistic approach focusing on more than simply the injection of an anesthetic. These considerations include addressing patient pre- and intraoperative anxiety, knowledge of local anesthetics and their additives, skill with appropriate injection techniques to reduce patient discomfort, and the ability to anticipate and address analgesia following the procedure and will be covered in this chapter.
Article
The aim of this review article is to provide many important tips and tricks for surgeons to start Wide Awake Local Anaesthesia No Tourniquet (WALANT) hand surgery in their practice. The massive cost reduction of this disruptive new approach will enable them to increase access to hand surgery for their patients who cannot afford unnecessary sedation or unnecessary sterility of the expensive main operating room environment. Evidence-based sterility will permit surgeons to move a lot of their surgery out of the main operating room to minor procedure rooms without a significant increase in infection rates. Important pointers on how to inject minimally painful local anaesthesia will have patients thinking the surgeon injector is a bit of a magician. WALANT enables surgeons to improve the outcomes of many hand surgery procedures. Level of Evidence: Level V (Therapeutic)
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Liposuction is the most common procedure in plastic surgery and becoming increasingly common in male patients. Recently, liposuction has evolved from a procedure whose goal was primarily fat extraction, to one that sculpts tissue with the goal of enhancing muscular definition. The popularity of high-definition liposuction has increased rapidly due to visibility on social media and has broadened the patient population presenting for liposuction, particularly among men. Herein, the authors review patient selection, surgical technique, and postoperative outcomes following high-definition liposuction in male patients.
Article
The aim of this study was to systematically review the effects of lidocaine mixed with epinephrine and bicarbonate in plastic surgery in terms of onset, duration, and the pain score.In PubMed, Embase, Web of Science, and the Cochrane Library, the terms "epinephrine" AND "lidocaine" AND "plastic surgery" were searched, resulting in 210 titles. Among them, 25 full papers were reviewed, 11 were excluded, and 5 mined papers were added. Therefore, 19 papers were analyzed.The mean time for the onset of maximum vasoconstriction caused by lidocaine with epinephrine (LE) ranged from 1.3 minutes (1:50,000 epinephrine) to 25.9 minutes (1:100,000 epinephrine). The mean duration of vasoconstriction caused by LE ranged from 40 minutes (1:100,000 epinephrine) to 136.7 minutes (1:50,000 epinephrine) on the forearm, and 60 minutes (1:100,000 and 1:200,000 epinephrine) on the face. The mean duration of local anesthesia ranged from 112.0 minutes (1:1,600,000 epinephrine) to 480 minutes (1:80,000 epinephrine). Before sodium bicarbonate (SB) was mixed with 1% lidocaine and 1:100,000 epinephrine, the mean pH ranged from 4.05 to 4.24. After mixing SB with 1% lidocaine and 1:100,000 epinephrine, the solution became alkalized, and the mean pH ranged from 7.05 to 7.66. For alkalization, the ratio of LE to SB was 9:1 to 10:1. Before alkalization of LE, the mean pain score ranged from 2.35 to 7.6. In contrast, after alkalizing the mixture by adding 8.4% SB, the mean pain score ranged from 0.64 to 4.3.The results of this study may be helpful for using lidocaine in plastic surgery.
Article
Introduction Epinephrine and sodium bicarbonate (NaHCO3) used in wide-awake local anesthesia no tourniquet (WALANT) affect many areas such as hemostasis, injection pain, anesthetic effect and others. However, few clinical trials have focused on injection pain and the duration of anesthetic effect, and no prospective studies have reported the benefits of WALANT post operation. This study compared WALANT with conventional local anesthesia with tourniquet in minor hand surgeries, and aimed to answer following questions: (1) Does WALANT have enough benefits for injection pain and duration of anesthetic effect?; (2) How does WALANT affect postoperative management (such as postoperative pain and use of analgesics)?; (3) How satisfied are the patients with the surgery? Hypothesis We hypothesized that WALANT had advantages in injection pain, duration of anesthetic effect, and postoperative management compared to conventional local anesthesia. Materials and methods The present study is designed as a randomized prospective one center study. This study included 185 patients who received surgical treatment for the diagnosis of carpal tunnel syndrome, trigger finger, or de Quervain's disease between 2017 and 2019. We randomly allocated the patients to either the WALANT group or the conventional group. We inquired and recorded patients’ injection pain, duration of anesthetic effect, postoperative pain, the use of analgesics, and satisfaction with the surgery. Results The injection pain was significantly lower in the WALANT group in all procedures (p < 0.001). The duration of anesthetic effect was significantly longer in the WALANT group in all procedures (p < 0.001). As for the postoperative management of all procedures, the pain score was significantly lower in the WALANT group until the first day after surgery, with the biggest difference at 6 hours after surgery. The use of analgesics was significantly lower in the WALANT group until the second day after surgery. Satisfaction with surgery was significantly higher in the WALANT group in all procedures: A1 pulley release (p = 0.026), 1st extensor retinaculum (p = 0.045), and carpal tunnel release (p = 0.003). Discussion Our study showed better results in WALANT than in the conventional method, with no tourniquet pain, lower injection pains, longer anesthetic duration, and less postoperative pain. It provided patients with great satisfaction. In addition, WALANT has the potential benefits of no time limit due to tourniquet pain and long anesthetic effect. Therefore, WALANT is comfortable and cost effective, and could be a good alternative to conventional local lidocaine anesthesia. Level of evidence II.
Article
Background This study aims to compare the use of one-per-mil tumescent solution (a mixture of epinephrine and 0.2% lidocaine in a ratio of 1:1,000,000 in normal saline solution) and tourniquet to create clear operative fields and to evaluate the functional outcomes after post burn hand contracture surgery. Methods The subjects of this randomized controlled trial were divided into one-permil tumescent technique and tourniquet group for a similar surgical procedure. Three independent assessors evaluated the clarity of the operative fields through recorded videos for the first 15 min and the first 10-minute of each hour of the surgery. Functional outcome was evaluated at least three months postoperatively using total active and passive motion (TAM and TPM) of each digit. Malondialdehyde (MDA) and tumor necrosis factor alpha (TNF-α) were tested during baseline (5 min before the procedures), ischemia phase, and reperfusion phase (a phase when the blood flow returned to the tissue). Results 35 subjects were included in this study: 17 in the tumescent group and 18 in the tourniquet group. There was a significant difference in the clarity of operative field between tumescent and tourniquet groups, 5 vs 35 bloodless operative fields, respectively (p < 0.05). TAM and TPM of each digit before surgery and 3 months postoperatively showed no significant difference between both groups (p > 0.05). Furthermore, there was no difference in the level of MDA and TNF-α between both groups at their respective phases. Conclusions The use of one-per-mil tumescent technique does not replace tourniquet use to create bloodless operative fields in postburn hand contracture surgery. However, the postoperative functional results were similar in both groups showing that tumescent technique can be used as an alternative to tourniquet without compromising the outcomes. The MDA and TNF-α examinations do not provide conclusive outcomes regarding ischemia and reperfusion injury.
Chapter
Management of tendon injuries is rather nuanced. Multiple factors affect the intraoperative decisions during tendon repair. A thorough understanding of anatomy, tendon biology, and repair techniques is critical. A comprehensive evaluation is also important. Many tendon repairs can be performed wide-awake with local anesthesia. In this chapter, basic science, evaluation, anesthesia considerations, and surgical techniques are discussed for tendon repair. Emphasis is placed upon wide-awake hand surgery, four core suture techniques, and postoperative early active range of motion with a certified hand therapist.
Article
Liposuction is one of the commonest surgical aesthetic procedures performed worldwide. Despite perceived to be a technically simple procedure, poor patient selection, sub-optimal technical execution or sub-optimal peri-operative management could lead to significant harm. This guidance was produced on behalf of the British Association of Aesthetic Plastic Surgeons (BAAPS) and British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) by the expert liposuction group. The guidance is based on evidence available in the literature along with specialist expert opinion in aesthetic liposuction to provide plastic surgeons with consensus recommendation. The aim is to identify best practice to maximise the safety of patients. This article summarises current practises and safety considerations and outlines recommendations covering various aspects of patient care.
Article
Wide-Awake Local Anesthesia No Tourniquet (WALANT) may be a satisfactory anesthesia alternative for the management of upper limb peripheral nerve palsy sequelae. The main advantages are the possibility of active patient cooperation through intraoperative active mobilization, comfort and cost reduction. The legislation about WALANT in France remains unclear; the modalities of lidocaine epinephrine injection should be redefined. For palliative upper limb surgery, WALANT allows the surgeon to adjust the tension on the tendon transfer intraoperatively. Level 1 studies are needed to evaluate the effectiveness of WALANT relative to standard anesthesia techniques (regional/general anesthesia).
Article
Full-text available
Wide-awake surgery is a surgical procedure which is not used a tourniquet and any sedation by using the function of lidocaine and epinephrine through the tumescent injection technique. The biggest advantages of wide-awake surgery are the prevention of the systemic risk of general anesthesia and the surgeon can confirm the result of surgery by moving the patient’s joint and tendon during the operation. But some modification of wide-awake surgery may be beneficial for the surgeon and patient. For decreasing the patient anxiety, low-grade sedative can be used and short-time use of tourniquet during initial dissection of the operating site can prevent the unexpected complication.
Article
Skin erythema may present due to many causes. One of the common causes is prolonged exposure to sunrays. Other than sun exposure, skin erythema is an accompanying sign of dermatologic diseases, such as psoriasis and acne. Quantifying skin erythema in patients enables the dermatologist to assess the patient's skin health. Quantitative assessment of skin erythema has been the target of several studies. The clinical standard for erythema evaluation is visual assessment; however, the former standard has some imperfections. For instance, it is subjective, and unqualified for precise color information exchange. To overcome these shortcomings, the past three decades has witnessed various methodologies that aimed to achieve erythema objective assessment, such as diffuse reflectance spectroscopy (DRS), and both optical and non-optical systems. This review appraises the studies published in the past three decades, where the performance, the mathematical tactics for computation, and the limited capabilities of erythema assessment techniques for cutaneous diseases are discussed. The current achievements and limitations of the current techniques in erythema assessment are presented. The profits and development trends of optical and non-optical methods are displayed to provide the researcher with awareness into the present technological advances and its potential for dermatological diseases research.
Article
We hypothesized that WALANT would provide similar perioperative analgesic comfort compared to local anesthesia with peripheral nerve blocks (LAPNV). We analyzed whether the patient’s active participation during surgery would improve its early functional results. We did a retrospective, single study in an outpatient surgery unit, comparing two types of surgery: trapeziometacarpal arthroplasty (TMCA) under LAPNV and TMCA under WALANT. Fifteen patients were included per group. Pain levels were determined during anesthesia induction, intraoperatively, postoperatively, at rest and during activity at the last follow-up visit. The overall satisfaction with the surgery and time to resume daily activities and work were documented. The statistical analysis was performed on SAS software with an ANOVA. The significance threshold was set at 0.05. The groups were comparable on age, sex, dominant side, and operated side. No patients were lost to follow-up. The mean follow-up was 4 months (2.3–11). The QuickDASH score was 4.93 for TMCA under WALANT vs. 13.47 for TMCA under LAPNV (p = 0.01). There was no loosening, dislocation, or major complication. Our study showed that TMCA performed with WALANT yields similar results to the same procedure with LAPNV for perioperative pain relief without additional complications. Functional scores seem to be slightly improved with WALANT compared to LAPNV, but these results should be confirmed with longer follow up.
Article
Background This study was designed to analyze the results of all wide awake local anesthesia no tourniquet (WALANT) procedures performed on the hand and wrist at a single practice hand surgery practice with a focus on quantifying and qualifying complications. Methods This retrospective chart review included 424 patients who underwent WALANT hand procedures in the minor procedure room of our private practice between 2015 and 2017. Patients were divided into groups based on the type of procedure, including carpal tunnel release, A1 pulley release, first dorsal compartment release, extensor tendon repair, mass excision, and foreign body removal. Data pertaining to patient demographics and complications were recorded. Results The overall complication rate for all procedures was 2.8% for 424 patients: A1 pulley release (n = 314, 2.5%), first dorsal compartment release (n = 11, 9%), extensor tendon repairs (5.5%), and mass excision (4%). The carpal tunnel release and foreign body removal groups experienced no complications. No adverse events (arrhythmias, vasovagal, etc.) were observed during the use of the WALANT technique. Conclusions Clinic-based WALANT hand surgery procedures are equally safe compared to the same procedures performed in the operating room at an ambulatory surgery center or hospital.
Article
Full-text available
Wide-awake flexor tendon repair in tourniquet-free unsedated patients permits intraoperative Total Active Movement examination (iTAMe) of the freshly repaired flexor tendon. This technique has permitted the intraoperative observation of tendon repair gapping induced by active movement when the core suture is tied too loosely. The gap can be repaired intraoperatively to decrease postoperative tendon repair rupture rates. The authors record their rupture rate in the first 15 years of experience with iTAMe. This was a retrospective chart review of 102 consecutive patients with wide-awake flexor tendon repair (no tourniquet, no sedation, and pure locally injected lidocaine with epinephrine anesthesia) in which iTAMe was performed by two hand surgeons in two Canadian cities between 1998 and 2008. Intraoperative gapping and postoperative rupture were analyzed. The authors observed intraoperative bunching and gap formation with active movement in flexor tendon repair testing (iTAMe) in seven patients. In all seven cases, they redid the repair and repeated iTAMe to confirm gapping was eliminated before closing the skin, and those seven patients did not rupture postoperatively. In 68 patients with known outcomes, four of 122 tendons ruptured (tendon rupture rate, 3.3 percent) in three of 68 patients (patient rupture rate, 4.4 percent). All three patients who ruptured had accidental jerk forced rupture. All those patients who did what we asked them did not rupture. Tendons can gap with active movement if the core suture is tied too loosely. Gapping can be recognized intraoperatively with iTAMe and repaired to decrease postoperative rupture.
Article
The addition of epinephrine to local anesthetics decreases bleeding, reduces systemic toxicity, and increases duration of action. However, epinephrine has significant side effects. Four concentrations of epinephrine were compared to determine the minimum concentration required for maximal vasoconstriction. Eighty-one subjects undergoing surgical procedures with general anesthesia were injected with 1% lidocaine containing varying concentrations of epinephrine. Blood flow measurements were then made at 1-minute intervals for 10 minutes using a laser Doppler flowmeter. There were no differences in blood flow reduction between epinephrine concentrations of 1:100,000, 1:200,000, and 1:400,000. However, epinephrine 1:800,000 provided significantly less vasoconstriction. We recommend using an epinephrine concentration of 1:200,000 or 1:400,000 to provide optimal initial hemostasis while minimizing potential side effects.
Article
The effectiveness of local anesthetics is improved by the addition of a vasoconstrictor which increases duration of action and decreases both systemic toxic reactions and local bleeding. Epinephrine, the standard drug for vasoconstriction, has some limitations due to potential dose-related cardiac and local toxic effects. The authors examined the minimal effective epinephrine concentration required for maximal cutaneous vasoconstriction in the human subject so as to limit potential dose-related side effects. In a randomized, double-blinded prospective study, 23 patients undergoing head and neck surgical procedures under general anesthesia were enrolled to quantify the effect of subdermal infiltration of 1% lidocaine with epinephrine at varying concentrations on local cutaneous bloodflow utilizing laser Doppler flowmetry. A comparison of the onset of vasoconstriction and magnitude of diminished bloodflow was made for several commonly used concentrations of epinephrine, with 1% lidocaine and normal saline serving as controls. There were no significant differences (P>.05) between epinephrine concentrations of 1:400,000, 1:200,000, 1:100,000, and 1:50,000 when examining onset and magnitude of vasoconstriction.
Article
Quantification of the effect of subcutaneous infiltration of saline with epinephrine and of lidocaine with epinephrine on local cutaneous blood flow was accomplished utilizing the laser Doppler method. A comparison of the onset of vasoconstriction, magnitude of diminished blood flow, and duration of effect was made for several commonly used concentrations of epinephrine. Injected solutions containing epinephrine in concentrations of 1: 200,000 and higher offered good vasoconstrictor effects when both the magnitude and duration of flow reduction were considered. There was a significant (P = 0.0001) difference in flow between epinephrine concentrations of 1:400,000 and all others. There were no significant differences (P > 0.05) between concentrations of 1:200,000 and 1:100,000 or 1:100,000 and 1:50,000.
Article
Wide awake hand surgery means no sedation, no tourniquet, and no general anesthesia for hand surgery. The only medications given to the patient are lidocaine with epinephrine. Lidocaine is for anesthesia, and epinephrine provides hemostasis, which deletes the need for a tourniquet. The advantages are: (1) the ability of the comfortable unsedated tourniquet-free patient to perform active movement of the reconstructed structures during surgery so the surgeon can make alterations to the reconstruction before the skin is closed to improve the outcome of many surgeries; and (2) the deletion of all risks, costs, and inconveniences of sedation and general anesthesia.
Article
Early recognition of threatened free-flap failure is paramount to flap salvage. A noninvasive, reproducible, sensitive monitoring tool would be a useful adjunct to clinical examination. The purpose of this study was to examine outcomes using a near-infrared spectroscopy (NIRS) tissue oximeter for postoperative flap monitoring. A total of 128 free flaps were performed in 113 patients over a 3 year period. The patients were divided into 2 cohorts: conventional monitoring (group 1) and conventional monitoring plus NIRS oximetry (group 2). Overall flap survival was 90.6% in group 1 and 98.7% in group 2 (P = 0.05). Overall survival of threatened flaps was 0% (0/5) in the conventional group and 87.5% (6/7) in the oximeter group, P = 0.005. Salvage of operated flaps was significantly improved in group 2: 0% (0/4) in group 1 versus 100% (3/3) in group 2, P = 0.03. The sensitivity, specificity, and predictive values for detecting threatened flap loss were 100%. The NIRS tissue oximeter is a highly reliable, sensitive, and specific, noninvasive method for postoperative free tissue transfer monitoring.
Article
Carpal tunnel release was performed under local anaesthesia in 108 wrists of 98 patients. The local anaesthetic (bupivacaine 0.5% and adrenaline) was injected into the subcutaneous tissue down to the flexor retinaculum in the line of the incision. The median nerve was not anaesthetised. No tourniquet was required and analgesia was complete in all but four patients, who complained of some minor discomfort on cutting the flexor retinaculum. Protracted postoperative analgesia was obtained.
Article
A theoretical treatment has been developed for the optical properties of a layered structure which absorbs and scatters light. This theory predicts that the logarithm of the inverse of reflectance (LIR) of the surface should be a useful parameter for the examination of that structure. This approach has been applied to a study of skin in vivo. An instrument was constructed for use in clinical situations to measure the LIR spectrum of skin over the visible region of the spectrum (450-760 nm). The contributions to the observed spectra made by pigments and the skin structure were deduced by reference to the theoretical model. Numerical indices were used to quantify the changes in skin haemoglobin content following the application of vasoconstricting preparations. The indices also provided a means of measuring erythema and melanin pigmentation induced in the skin by exposure to ultraviolet radiation. The assessments made using this instrument were more reproducible and sensitive than judgments made by eye.
Article
Photodynamic therapy (PDT) uses light-activated drugs to treat diseases ranging from cancer to age-related macular degeneration and antibiotic-resistant infections. This paper reviews the current status of PDT with an emphasis on the contributions of physics, biophysics and technology, and the challenges remaining in the optimization and adoption of this treatment modality. A theme of the review is the complexity of PDT dosimetry due to the dynamic nature of the three essential components -- light, photosensitizer and oxygen. Considerable progress has been made in understanding the problem and in developing instruments to measure all three, so that optimization of individual PDT treatments is becoming a feasible target. The final section of the review introduces some new frontiers of research including low dose rate (metronomic) PDT, two-photon PDT, activatable PDT molecular beacons and nanoparticle-based PDT.
Grabb and Smith's Plastic Surgery
  • Dm Knize
  • Forehead
  • Ch Thorne
  • Rw Beasley
  • Sj Aston
  • Sp Bartlett
  • Gc Gurtner
  • Sl Spear
Knize DM. Forehead lift. In: Thorne CH, Beasley RW, Aston SJ, Bartlett SP, Gurtner GC, Spear SL, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2007:509–517.