The Role of Blood Pressure Control in Prevention of Hematoma After Blepharoplasty.

INTRODUCTION: Hematoma formation after blepharoplasty is serious and potentially vision-threatening, with hypertension being the primary risk factor. The aim of this paper is to assess perioperative blood pressure trends and rates of complication in patients undergoing a strict blood pressure protocol designed to keep perioperative systolic blood pressure below 120 mmHg. METHODS: A retrospective chart review was performed of 32 patients undergoing face lift with conomitant blepharoplasty from January 2015 to July 2018. For each patient blood pressure readings obtained before, during, and after surgery were reviewed. Two-sample one-tail T-tests were performed, and p values less than 0.05 were considered statistically significant. RESULTS: The mean systolic blood pressure (SBP) for all patients was highest intraoperatively. Patients with known hypertension had higher mean SBPs than patients without hypertension across all phases of care, with a statistically significant difference in immediate preoperative SBP (p=0.05). Males had a higher average blood pressure immediately postoperatively (p=0.05). A previous diagnosis of hypertension in females was associated with a higher immediate preoperative SBP (p=0.07) as well as age over 65 (p=0.07). The overall rate of complications was 37.5%. No patients experienced hematoma. CONCLUSION: This study demonstrated that keeping blood pressure below 120 mmHg after surgery was an effective method of preventing hematoma after blepharoplasty, even in patients concurrently on anti-coagulative medications. Special attention to blood pressure control should be shown to patients with known risk factors such as a previous diagnosis of hypertension, male sex, or age greater than 65. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Objective Comparison of Donor-Site Morbidity following Full and Thoracodorsal Nerve-Preserving Split Latissimus Dorsi Flaps.

BACKGROUND: The latissimus dorsi flap is a workhorse for reconstruction. However, flap harvest has been variably reported to result in donor-site morbidity. The aim of this study was to compare donor-site morbidity following harvest of a split latissimus dorsi flap, preserving the anterior branch of the thoracodorsal nerve, and a traditional nerve-sacrificing full latissimus dorsi flap. METHODS: Patients who underwent split or full latissimus dorsi flaps between July of 2017 and August of 2020 at a single center were recalled for assessment. Donor-site morbidity in the shoulder was evaluated through the Disabilities of the Arm, Shoulder and Hand questionnaire; the Shoulder Pain and Disability Index; and the American Shoulder and Elbow Surgeons questionnaire. Medical Research Council strength grading was also performed. RESULTS: A total of 22 patients in the split latissimus dorsi cohort and 22 patients in the full latissimus dorsi cohort were recalled. Patient-reported outcomes as assessed through the Disabilities of the Arm, Shoulder and Hand questionnaire; Shoulder Pain and Disability Index; and American Shoulder and Elbow Surgeons questionnaire scores revealed statistically greater (p < 0.05) donor-site morbidity associated with the traditional compared to split latissimus dorsi flap. Seven patients in the full latissimus dorsi cohort had less than Medical Research Council grade 5 power at the shoulder, whereas all patients in the split latissimus dorsi cohort demonstrated full power at the shoulder. CONCLUSIONS: Traditional full latissimus dorsi flaps were found to result in greater donor-site morbidity compared to thoracodorsal nerve-preserving split latissimus dorsi flaps. Split latissimus dorsi flaps may be beneficial in preserving donor-site function and strength. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Separating Fact From Fiction: A Nationwide Longitudinal Examination of Complex Regional Pain Syndrome Following Treatment of Dupuytren Contracture.

BACKGROUND: One of the most feared complications following treatment of Dupuytren contracture is complex regional pain syndrome (CRPS). This study aims to provide a national perspective on the incidence of CRPS following treatment of Dupuytren contracture and identify patient factors to target for risk reduction. METHODS: Using the Truven MarketScan databases from 2007 to 2016, individuals aged ≥18 years who developed CRPS within 1 year of treatment of Dupuytren contracture were identified using the International Classification of Disease diagnosis code for CRPS. Predictor variables included: age, sex, employment status, region, type of procedure, and concurrent carpal tunnel surgery. Multivariable logistic regression was used to analyze outcomes. RESULTS: In all, 48 327 patients received treatment for Dupuytren contracture, including collagenase injection (13.6%); percutaneous palmar fasciotomy (10.3%); open palmar fasciotomy (3.9%); palmar fasciectomy with 0 (10.8%), 1 (29.2%), or multiple (19.6%) digit releases; or a combination of these procedures (12.8%). One hundred forty-five patients (0.31%) were diagnosed with CRPS at a mean of 3.4 months (standard deviation, 2.3) following treatment. Significant predictors of CRPS included female sex (odds ratio [OR], 2.02; P < .001), Southern region (OR, 1.80; P = .022), long-term disability status (OR, 4.73; P = .035), palmar fasciectomy with release of 1 (OR, 5.91; P = .003) or >1 digit (OR, 13.32; P < .001), or multiple concurrent procedures for Dupuytren contracture (OR, 8.23; P = .001). CONCLUSIONS: Based on national commercial claims data, there is a lower incidence of CRPS following treatment of Dupuytren contracture than previously reported. Risk factors identified should help with preoperative counseling and assist clinicians in targeting risk reduction measures.

Complete Transection of the Median Nerve with Distal Radius Fracture: A Case Report.

CASE: We report a case of complete median nerve transection due to a distal radius fracture. In the setting of high energy trauma and a widely displaced fracture, a volar ulnar spike from the proximal fragment likely transected the median nerve. After open reduction and internal fixation of the distal radius fracture, the median nerve was repaired directly. Postoperative radiographs at 10 weeks revealed a healed fracture with clinical examination, showing good pain-free range of motion at the radiocarpal joint. CONCLUSION: This case suggests that exploration and visualization of the median nerve to exclude injury may be considered on a case-by-case basis in the presence of sensory and motor symptoms, suggesting median nerve dysfunction after a highly displaced distal radius fracture.

Immature megalin expression in the preterm neonatal kidney is associated with urinary loss of vitamin carrier proteins.

BACKGROUND: Vitamin A and D deficiencies are common in preterm infants. Megalin is an endocytic receptor in the proximal tubule, which reabsorbs retinol-binding protein (RBP) and vitamin D-binding protein (VDBP). Although the proximal tubule is immature in preterm infants, little is known about megalin expression during kidney development. In this study, we establish the abundance of megalin in the developing human kidney and its relationship to the urinary excretion of vitamin carriers in preterm infants. METHODS: We analyzed a postmortem group (20-40 weeks gestation), where we used morphometric means of measuring megalin and its ligands in kidney tissue and a living group of patients (28-40 weeks), where urinary RBP and VDBP were measured. RESULTS: The presence of megalin, RBP, and VDBP increased in the proximal tubule through gestation. At birth the urinary concentration of RBP and VDBP were higher in the 28-32 week group compared to the 38-40 week group and a significant inverse correlation of tissue megalin and urinary loss of RBP and VDBP existed. CONCLUSIONS: Preterm infants experience vitamin carrier protein losses, which are associated with decreased megalin expression. This developmental expression of megalin in the kidney has clinical implications in the prevention of vitamin deficiencies in preterm babies.

Break Scrub to Take That Phone Call?

BACKGROUND: The American College of Surgeons reports that 60% of the hundreds of thousands of surgical site infections occurring annually are preventable. The practice of surgeons taking phone calls while remaining sterile in the operating field is often accomplished by interposing a sterile disposable towel between the phone and their glove. After completing the call, surgeons resume operating. The purpose of our study was to test the conceptual idea of whether bacteria transmit from an inanimate object, such as a telephone, to the gloves of a surgeon through a sterile disposable towel. STUDY DESIGN: Glo Germ (Glo Germ Co), an ultraviolet light-enhanced particle powder sized to mimic bacteria, was placed on an inanimate surface and held with a sterile disposable operating room towel covering a sterile surgical glove. The glove was then inspected for Glo Germ using an ultraviolet light. Additionally, 18 operating room telephones were cultured and then held with a Sterile Disposable OR Towel (Medline Industries Inc) covering a sterile surgical glove. The surgical gloves were then cultured to determine if bacteria had transmitted from the telephone through the towel and onto the sterile glove. RESULTS: The Glo Germ powder readily transmitted through the towel to the gloves. Median colony-forming units (CFU) on the cultured telephones for the 17 samples was 10, ranging from 1 to 35 CFUs. Of these 17 samples, 47% had transmission from the telephone to the glove, which was significantly greater than 0% (95% CI 26% to 69%, p < 0.001). CONCLUSIONS: Sterile disposable operating room towels do not provide an effective barrier between bacteria present on operating room telephones and the otherwise sterile gloves of a surgeon.