Pain Relief Durations of Different Concentrations of Lidocaine in Wide Awake Hand Surgery: A Prospective Randomised Clinical Trial.

OBJECTIVE: This study aims to determine the minimal concentration of lidocaine to provide adequate analgesia in wide awake local anaesthesia no tourniquet (WALANT) hand surgeries comparing 3 dilutions of tumescent lidocaine with epinephrine solution. STUDY DESIGN: A randomised control trial. Place and Duration of the Study: The study was held at the Plastic Surgery Department of Mayo Hospital, Lahore, from September 2020 to March 2021. METHODOLOGY: Inclusion criteria were post-traumatic hand contractures and tendon and nerve injuries. The patients were randomised to 3 groups of 30 each: Group A (0.1% lidocaine), Group B (0.2% lidocaine), and Group C (0.3% lidocaine). The dilution of adrenaline also remained constant at 1:200,000. Pain was measured using the Visual Analogue Scale. The three groups were compared for demographics and the total duration of analgesia in minutes. RESULTS: All groups showed adequate pain relief during surgery with no cases requiring conversion to general anaesthesia. The highest total duration of analgesia was seen in the 0.3% group (805.3±195.2 minutes), followed by the 0.2% group (500.4±87.2 minutes) and 0.1% group (381.3±31.6 minutes) (p<0.05). No patient developed any signs of lidocaine toxicity. A low Lidocaine concentration of 0.1% was effective in providing analgesia during surgery though increasing the lidocaine concentration to 0.3% would result in greater post-operative analgesic time without increasing toxicity. CONCLUSION: Adequate analgesia was recorded with all 3 lidocaine concentrations. The greatest pain-free duration was however observed in the  0.3% lidocaine group. KEY WORDS: Wide awake local anaesthesia no tourniquet (WALANT), Lidocaine concentrations, Hand surgery, Analgesia, Adverse effects.

Outcomes of islanded scrotal raphe flap employment for skin shortage in complicated hypospadias repair.

BACKGROUND: Ventral skin deficiency in complicated hypospadias is a difficult problem to treat. The aim of our study is to report our technique and outcomes of vascularized islanded scrotal raphe flap for ventral skin deficiency in complicated hypospadias. METHODS: A retrospective review was conducted at Northwest General Hospital & Research Centre, Peshawar, from January 2012 to January 2019. Complicated hypospadias patients who underwent two-stage surgery employing islanded scrotal flap were identified. Patients underwent surgery in two stages: scar tissue removal, chordee correction and buccal mucosal graft in the first stage; neourethral tubularization, water proofing, and skin coverage with vascularized islanded scrotal raphe flap in the second stage. The primary outcome was 6-month flap survival rate. Secondary outcomes were 6-month complication rate (fistula, persistent chordee, distal stenosis) and end-of-follow-up patient self-reported satisfaction rate. RESULTS: A total of 1845 patients underwent hypospadias surgery, of which 380 patients had complications. Scrotal raphe flap was used in 45 patients. Mean age was 14.09 (±8.02) years. Mean follow-up was 29.78 (±12.18) months. Mean number of previous surgeries was 4.31 (±2.59). The flap survived in all cases. Nine patients (20%) developed complications. One patient (2.2%) developed distal stenosis. Eight patients (17.8%) developed fistulas, one of whom additionally had persistent chordee. Five fistulas closed spontaneously within 3 months, while the rest were repaired surgically after 6 months. All patients self-reported satisfaction with results at end-of-follow-up. CONCLUSIONS: Islanded Scrotal Raphé flap is a promising option for treating complicated hypospadias when there is significant ventral deficiency of skin, as it not only provides vascularized pliable skin but also fascia as a waterproofing layer.

Unfiltered Nanofat Injections Rejuvenate Postburn Scars of Face.

The aim of this study was to compare the quality of postburn facial scars before and after injection of unfiltered nanofat. The study was performed in the Plastic Surgery Department of Mayo Hospital, Lahore, Pakistan, from January 2015 to December 2016. Forty-eight patients with postburn facial scars were included; age range was 4 to 32 years with Fitzpatrick skin types between 3 and 4. Patients with hypertrophic scars, contractures, or keloids were excluded. Scars were assessed by a senior plastic surgeon and the patient on the POSAS (Patient Observer Scar Assessment Scale). Fat was harvested from the abdomen and/or thighs with a 3-mm multiport liposuction cannula (containing several sharp side holes of 1 mm) using Coleman technique. The harvested fat was emulsified and transferred into 1-mL Luer-Lock syringes for injection into the subdermal or intradermal plane. Final follow-up was scheduled at 6 months, and scar was rated by the patient and the same surgeon on the POSAS. Preoperative and postoperative scar scores were compared, and P values were calculated. Results indicated that after nanofat grafting, there was a statistically significant improvement in scar quality. The most significant improvements on the observer scale were seen in pigmentation and pliability (P < 0.0001). Thickness and relief were the least improved variables (P = of 0.785 and 0.99, respectively). ImageJ scanning also showed pigmentation change (P = 0.076). A statistically significant improvement was seen in all parameters of the patient section of the POSAS (P < 0.0001). In conclusion, unfiltered nanofat grafting seems to be a promising and effective therapeutic approach in postburn facial scars, showing significant improvement in scar quality. The trial was registered on www.clinicaltrials.gov with following ID NCT03352297.

Traumatic Wounds of the Upper Extremity: Coverage Strategies.

Soft tissue coverage of traumatic wounds of the upper extremity is often required to restore adequate function and form. An optimal coverage should be stable, durable, and able to withstand heavy demands of work, should allow free joint mobility, and should have an aesthetically acceptable appearance. Reconstructive options for coverage include autologous tissue and dermal skin substitutes. Multiple factors, including wound characteristics and complexity, general condition of the patient, and surgeon comfort and expertise, help in selection of the reconstructive technique. This article summarizes commonly used soft tissue reconstructive options for traumatic wounds of the upper extremity.

Comparison of Laser Doppler Imaging (LDI) and clinical assessment in differentiating between superficial and deep partial thickness burn wounds.

PURPOSE OF PRESENTATION/STUDY: To compare the accuracy of Laser Doppler Imaging (LDI) and clinical assessment in differentiating between superficial and deep partial thickness burns to decide whether early tangential excision and grafting or conservative management should be employed to optimize burn and patient management. STUDY PERIOD: March 2015 to November 2016. METHODS/PROCEDURE DETAILS: Ninety two wounds in 34 patients reporting within 5days of less than 40% burn surface area were included. Unstable patients, pregnant females and those who expired were excluded. The wounds were clinically assessed and LDI done concomitantly Plastic Surgeons blinded to each other's findings. Wound appearance, color, blanching, pain, hair follicle dislodgement were the clinical parameters that distinguished between superficial and deep partial thickness burns. On day 21, the wounds were again assessed for the presence of healing by the same plastic surgeons. The findings were correlated with the initial findings on LDI and clinical assessment and the results statistically analyzed. RESULTS/OUTCOME: The data of 92 burn wounds was analyzed using SPSS (ver. 17). Clinical assessment correctly identified the depth of 75 and LDI 83 wounds, giving diagnostic accuracies of 81.52% and 90.21% respectively. The sensitivity of clinical assessment was 81% and of LDI 92.75%, whereas the specificity was 82% for both. The positive predictive value was 93% for clinical assessment and 94% for LDI while the negative predictive value was 59% and 79% respectively. CONCLUSIONS: Predictive accuracy of LDI was found to be better than clinical assessment in the prediction of wound healing, the gold standard for wound healing being 21 days. As such it can prove to be a reliable and viable cost effective alternative per se to clinical assessment.

Management of eczema herpeticum in a Burn Unit.

OBJECTIVE: To study the clinical features, course and outcome of eczema herpeticum in burn patients. METHODS: This prospective study was conducted at the King Edward Medical University / Mayo Hospital, Lahore, Pakistan, from November 2012 to October 2015, and comprised eczema herpeticum patients. Demographic and clinical features of the patients, treatment protocols and outcomes were noted. SPSS 18 was used for data analysis. RESULTS: Of the 18 patients, 10(56%) were females and 8(44%) were males. The overall mean age was 29.17±8.36 years. The mean total body surface area burnt was 30.83±8.58%. Besides, 7(39%) patients had 2nd degree burns and 11(61%) had both 2nd and 3rd degree burns. There was no history of previous skin disease. Moreover, 4(22%) patients had diabetes and 6(33%) were smokers. The mean difference between the occurrence of fever and the appearance of skin lesions was 4.44±1.46 days. The overall mean temperature was 102.22±1.06 oF. The mean duration between the eruption of skin lesions and crusting of lesions was 4.38±1.26 days. Areas involved with skin lesions were trunk in 13(72%) patients, arms 12(67%), thigh 10(56%) and face in 4(22%) patients. Also, 2(11.1%) patients developed acute respiratory distress syndrome. Tzanck test showed multi-nucleated giant cell in all patients. The mean number of days since the eruption of lesions and the settling of fever was 5.56±0.73 days. The mean duration for complete healing, which occurred in 16(89%) patients, was 3.81±0.75 weeks. The overall mean follow-up period was 15±2.03 months. CONCLUSIONS: Eczema herpeticum may occur in a burn patient and should never be missed as early diagnosis will lead to a better outcome.