Cu-MOF loaded chitosan based freeze-dried highly porous dressings with anti-biofilm and pro-angiogenic activities accelerated Pseudomonas aeruginosa infected wounds healing in rats.

Metal-organic frameworks (MOFs)-based therapy opens a new area for antibiotic-drug free infections treatment. In the present study, chitosan membranes (CS) loaded with two concentrations of copper-MOF 10 mg/20 ml (Cu-MOF10/CS) & 20 mg/20 ml (Cu-MOF20/CS) were prepared by a simple lyophilization procedure. FTIR spectra of Cu-MOF10/CS and Cu-MOF20/CS dressings confirmed absence of any undesirable chemical changes after loading Cu-MOF. The SEM images of the synthesized materials (CS, Cu-MOF10/CS & Cu-MOF20/CS) showed interconnected porous structures. Cytocompatibility of the materials was confirmed by fibroblasts cells culturing and the materials were hemocompatible, with blood clotting index <5 %. Cu-MOF20/CS showed comparatively higher effective antibacterial activity against the tested strains; E. coli (149.2 %), P. aeruginosa (165 %) S. aureus (117.8 %) and MRSA (142 %) as compared to Amikacin, CS and Cu-MOF10/CS membranes. Similarly, Cu-MOF20/CS dressing significantly eradicated the biofilms; P. aeruginosa (37 %) and MRSA (52 %) respectively. In full thickness infected wound rat model, on day 23, Cu-MOF10/CS and Cu-MOF20/CS promoted wound healing up to 87.7 % and 82 % respectively. H&E staining of wounded tissues treated with Cu-MOF10/CS & Cu-MOF20/CS demonstrated enhanced neovascularization and re-epithelization along-with reduced inflammation, while trichrome staining exhibited increased collagen deposition. Overall, this study declares Cu-MOFs loaded chitosan dressings a multifunctional platform for the healing of infected wounds.

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.

Comparing definitive unilateral cleft rhinoplasty with and without diced-cartilage alar-base augmentation: A retrospective cohort study.

This retrospective cohort study aimed to compare the long-term aesthetic outcomes and satisfaction of patients who underwent two techniques of definitive unilateral cleft rhinoplasty. The two cohorts, comprising patients with mature unilateral cleft deformity, were managed with definitive rhinoplasty, either with or without diced-cartilage alar-base and peri-alar augmentation (ABPA). Thirty patients were included in each cohort. Anthropometric measurements, complications, patient satisfaction scores, and third-party surgeon assessment scores were reviewed. In both cohorts, anthropometric parameters improved. Rhinoplasty with ABPA was the superior cohort in terms of columellar length (10.3 ± 1.0 in the cohort with ABPA, compared with 7.9 ± 0.6 in the cohort without ABPA; p < 0.001), alar-base angle (0.2 ± 0.2, compared with 4.3 ± 0.3; p < 0.001), and columellar deviation (2.5 ± 1.4, compared with 10.3 ± 2.1; p < 0.001). This cohort also had more symmetry in nostril height and nostril width (p < 0.001), a lower recurrence rate (one case compared with 22 cases; p < 0.001), a higher patient satisfaction score (p = 0.002), and a higher surgeon assessment score (p < 0.001, Cronbach's alpha = 0.706, Kendall's coefficient of concordance = 0.787). Within the limitations of this study, it appears that the described technique for augmenting the alar-base and peri-alar maxillary area is manageable, and yields consistent long-term results.

Exploiting the power of Gamification in Journal club.

OBJECTIVE: To compare the effect of individual versus team competition gamification on trainees' engagement in journal club. METHODS: The quasi-experimental study was conducted at two tertiary care hospitals in Lahore, Pakistan, from December, 2019 to May, 2020, and comprised all plastic surgery residents in training years 3-5 who had attended non-gamified journal club sessions. They were divided into two groups. Initially, two journal club sessions were run in a gamified manner. Group 1had an individual competition whereas group 2 had a team competition. In the second phase, the group orientation was reversed. Engagement scores were measured using the student engagement survey tool at baseline, at the completion of the first part, and at end of the intervention. Data was analysed using SPSS 22. RESULTS: Of the 44 participants, 23(52.3%) were in group 1 and 21(47.7%) in group 2. Overall, there were 27(61%) females and 17(39%) males. The mean age of the sample was 31±2 years. Gamification resulted in significant increase in the level of residents' engagement in journal club activities compared to the baseline scores(p<0.05). There was no significant inter-group difference in the post-intervention engagement scores (p>0.05). CONCLUSIONS: Gamification designs used in the journal club activity increased student engagement level compared to the pre-intervention score, but gamification design was not a significant factor in this regard.

Primary Pharyngeal Flap With Palate Repair Improves Speech Outcome in Older Children and Adults: A Comparative Study.

BACKGROUND: Repair of cleft palate after 6 years of age is controversial in regard to the surgical procedure and the speech outcome. Primary repair alone may not be considered sufficient to achieve intelligible speech. The authors consider addition of pharyngeal flap at the time of primary repair to be a significant factor in improving speech. METHODS: Prospectively maintained data of all cleft palate patients operated from 2013 to 2017 (5 years) was analyzed to identify patients older than 6 years. Complete cleft palate, incomplete cleft palate, and cleft of the soft palate were further stratified according to different Randall types. They were divided into 2 main types: primary palate repair only and primary palate repair with pharyngeal flap. Speech was assessed preoperatively and 12 months postoperatively by Pittsburgh weighted speech scale. RESULTS: A total of 139 patients were analyzed. There were 78 males and 61 females. Their ages ranged from 6 to 60 years (mean age, 12.5 years). The overall preoperative speech score in palate repair-only group was 12.15, whereas the postoperative score was 7.32. In patients who underwent primary pharyngeal flap along with palate repair, the preoperative speech score was 11.3, and the postoperative score was 3.76. CONCLUSIONS: In select group of patients who report late for palate repair, addition of pharyngeal flap along with the primary palate repair improves the speech outcome in all Randall groups.

Adipose Tissue Grafting Improves Contour Deformities Related Hyperpigmentation of Face.

Contour deformities of face are commonly associated with overlying skin hyperpigmentation. Such hyperpigmentation causes aesthetic problems as well as makes contour deformities more prominent. Conventional surgical and cosmetic approaches to treat hyperpigmentation have limitations and therefore it is imperative to use other innovative techniques to simultaneously heal the contour deformity and also to remove hyperpigmentation. The current study aims to evaluate the effect of autologous adipose tissue in improving contour deformities related hyperpigmentation of face. One hundred patients with contour deformities related hyper-pigmentation of overlying skin were enrolled from February 2017 to January 2018. Adipose tissue was harvested from each patient and processed under sterilized conditions. Purified fat collected in a 10cc Luer-Lok syringe was transferred to 1cc syringes and injected into affected areas of face. The patients were followed for 12 months after adipose tissue injections. Both subjective and objective assessment was performed before treatment and 12 months after adipose tissue injections. Results indicated that after adipose tissue grafting, there was a statistically significant improvement in hyperpigmentation of skin. Most of the patients were highly satisfied after use of adipose tissue injections. Image J scanning also showed significant changes in hyperpigmentation of face after adipose tissue use. In all parameters, the patient exhibited statistically significant improvement. In conclusion, autologous fat grafting is a promising and effective therapeutic approach for hyperpigmentation associated with contour deformities of face.

Developing affordable and accessible pro-angiogenic wound dressings; incorporation of 2 deoxy D-ribose (2dDR) into cotton fibres and wax-coated cotton fibres.

The absorption capacity of cotton dressings is a critical factor in their widespread use where they help absorb wound exudate. Cotton wax dressings, in contrast, are used for wounds where care is taken to avoid adhesion of dressings to sensitive wounds such as burn injuries. Accordingly, we explored the loading of 2-deoxy-D-ribose (2dDR), a small sugar, which stimulates angiogenesis and wound healing in normal and diabetic rats, into both types of dressings and measured the release of it over several days. The results showed that approximately 90% of 2dDR was released between 3 and 5 days when loaded into cotton dressings. For wax-coated cotton dressings, several methods of loading of 2dDR were explored. A strategy similar to the commercial wax coating methodology was found the best protocol which provided a sustained release over 5 days. Cytotoxicity analysis of 2dDR loaded cotton dressing showed that the dressing stimulated metabolic activity of fibroblasts over 7 days confirming the non-toxic nature of this sugar-loaded dressings. The results of the chick chorioallantoic membrane (CAM) assay demonstrated a strong angiogenic response to both 2dDR loaded cotton dressing and to 2dDR loaded cotton wax dressings. Both dressings were found to increase the number of newly formed blood vessels significantly when observed macroscopically and histologically. We conclude this study offers a simple approach to developing affordable wound dressings as both have the potential to be evaluated as pro-active dressings to stimulate wound healing in wounds where management of exudate or prevention of adherence to the wounds are clinical requirements.

Motor cycle spoke wheel injuries in children: A preventable accident.

BACKGROUND: The incidence of motorcycle-induced spoke wheel injury is on the rise in our set up. These injuries range from minor soft tissue laceration to extensive crush injuries. This study aimed to evaluate the mechanism, characteristics, incidence and management of wheel spoke injuries. METHODS: Data of all children admitted to Pediatric Surgery Emergency from January 2014 to December 2017, presenting with wheel spoke injuries were analyzed. Incidence, mechanism and characteristics of injury, along with management plan, were noted. The outcomes were assessed by evaluating patients in follow up. RESULTS: Total study patients were 120, with an incidence of 21.7%. Mean age was 8.03±2.28 years. There were 101male patients and nine female patients. All patients were passengers and were sitting astride. Most of the patients were wearing shoes, and hindfoot area of the right foot was mainly involved. Grade 2 injury was seen in 55 (45.8%) and Grade 3 in 55 (45.8%) patients. Flap was needed in 27(22.5%) patients. All patients were mobile at the time of the follow-up. CONCLUSION: We noted the rising incidence of entrapment injuries; however, we had a satisfactory outcome in our patients using different management techniques. We recommend the implementation of safety protocols to avoid such catastrophic injuries.

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.

Outcomes of post burn flexion contracture release under tourniquet versus tumescent technique in children.

OBJECTIVE: To compare the clinical outcomes of release of flexion contractures after burn of the hand in children using tourniquet or tumescent technique in terms of operative time, postoperative pain score, and percentage of graft take. METHODS: Patients aged 3 to 12 years who required release of post-burn flexion contractures involving volar aspect of palm and fingers were enrolled from outpatient clinic. Patients were randomized in 1:1 ratio to the use of either tumescent technique or tourniquet during contracture release. Duration of procedure, postoperative pain score, percentage of graft take, and any complications were assessed and analyzed in both groups by a blinded observer. RESULTS: Of the 160 patients randomized in the study (80 in each group), 84 (52.5%) were males. The mean±SD age of participants was 7.84±3.49 years, with no statistically significant difference in gender and age distribution between the groups. Similarly, there was no statistically significant difference in duration of surgery in both groups. However, there was a statistically significant difference in percentage of graft take at the 14th postoperative day; significantly more graft take was noted in the tumescent group (8.97±3.7cm vs. 7.26±2.6cm; P=0.001). Mean analgesia consumed in the tumescent group was significantly less than that of the tourniquet group (6.26±1.9mg vs. 9.41±2.2mg; P≤0.001). Similarly, statistically significant difference in the mean FLACC pain score was noted, with remarkably low pain score in the tumescent group. CONCLUSION: We found that the use of the tumescent technique for the release of flexion contracture resulted in better graft take, lower pain scores, and lesser consumption of analgesic than the use of tourniquet.

Outcome of Conventional Adipose Tissue Grafting for Contour Deformities of Face and Role of Ex Vivo Expanded Adipose Tissue-Derived Stem Cells in Treatment of Such Deformities.

OBJECTIVES: To evaluate the outcomes of conventional fat grafting for facial contour deformities and to describe clinical outcome of a patient with contour deformity of face treated with ex vivo expanded adipose tissue-derived mesenchymal stem cells (ASCs) enriched fat graft. PLACE AND DURATION OF STUDY: The Department of Plastic Surgery and Tissue Engineering and Regenerative Medicine Laboratory, King Edward Medical University/Mayo Hospital, Lahore, from September 2015 to September 2017. METHODS: Patients with contour deformities of face requiring soft tissue augmentation were included. Fat was harvested, processed, and injected following a standard protocol. Both subjective and objective assessments were performed and complications were also noted. RESULTS: Twenty-five patients underwent 51 fat-grafting sessions over a period of 24 months. Eighteen (72%) patients underwent multiple fat-grafting sessions. Mean (standard deviation) soft tissue thickness after 72 hours and 6 months of first fat graft session was 18.62 (7.2) and 12.88 (6.21) mm, respectively, which corresponds to 30.77 (13)% reduction of transplanted fat. Physician and patient assessment scores were 3.42 (0.92) and 4 (1.04), respectively. Few minor complications were observed. In the patient undergoing ex vivo expanded ASCs enriched fat graft, there was minimal decrease in soft tissue thickness of treated area (44 mm vs 42 mm) 6 months postoperatively and patient was highly satisfied with the outcome after the single session. CONCLUSION: Conventional fat grafting is safe for correction of facial contour deformities. However, procedure needs to be repeated multiple times to produce satisfactory results. Beneficial effects of ex vivo expanded ASCs enriched fat grafting have a potential to alter the current treatment paradigm of fat grafting for soft tissue reconstruction.

A Modified Suction-Assisted Technique of Transfer of Diced Cartilage Graft to Carrier Material and Outcome of Direct Injection of Unwrapped Diced Cartilage in Rhinoplasty.

OBJECTIVE: To describe a modified suction-assisted technique (MSAT) of transfer of diced cartilage (DC) graft to a carrier material and to determine the clinical outcome of direct injection of unwrapped diced cartilage (UDC) in rhinoplasty. PLACE AND DURATION OF STUDY: Department of Plastic Surgery, KEMU, Mayo Hospital, Lahore from February 2011 to January 2015 METHODS:: Forty-seven patients of both genders with types 0 to 3 saddle nose deformity were included. Patients with types 4 and 5 saddle nose deformity, diabetes, hypertension, hepatic or renal disorders were excluded. Open tip rhinoplasty was performed in all patients. Eighth and/or ninth costal cartilage was harvested. Cartilage graft was diced into 1 to 2 mm pieces. The DC graft was transferred to carrier material (1-mL syringe) with MSAT. The UDC was then injected into nose and clinical outcome was determined. RESULTS: Out of 47 patients included in the study 62% were females with mean (standard deviation [SD]) age 22 (4) years. Thirty-four (72%) procedures were primary rhinoplasties while 13 (28%) were secondary rhinoplasties. Mean (SD) carrier material filling time was 12±3 seconds. All operating surgeons involved in study were satisfied with modified suction technique and declared it better than the traditional manual technique of filling the carrier material. Most of the patients were satisfied with their postoperative nasal appearance and complications were minimal. One patient required revision of surgery due to dorsal contour irregularities and another due to partial cartilage absorption at 13 ±â€Š2 months follow-up. CONCLUSION: Our MSAT of transfer of DC and injection of UDC is simple, easy to perform, reduces operative time and produces acceptable cosmetic outcome as regard patient's satisfaction.

Outcome of Management of Vascular Malformations of Lip.

OBJECTIVES: To describe the characteristics and outcome of management of vascular malformations of lip. PLACE AND DURATION OF STUDY: The Department of Plastic Surgery and Burn Unit, King Edward Medical University, Mayo Hospital, Lahore, from January 2009 to December 2013. METHODS: A prospective case series of 38 patients with vascular malformation of lip was performed. Demographic information and clinical features were noted. Treatment employed, complications, functional, and cosmetic outcome were recorded. Surgical debulking was performed as definitive treatment in all patients and nonsurgical techniques were added as adjuvant modalities in 18 patients. Sclerotherapy was performed for venous malformations in 10 patients. LASER was performed in 8 patients with capillary or combined malformations. Arterial malformations were managed surgically without embolization. Postexcision defects were closed primarily in 36 patients with Abbe flap in 1 and nasolabial flap in another patient for reconstruction. RESULTS: Of 38 patients included in the study 20 (53%) were males with mean (SD) age 18 (6) years. Twenty-one percent were high and 79% low-flow malformations (29% venous, 16% capillary, and 34% combined). Lower lip was involved in 70% patients with 95% having difficulty in eating and 87% abnormal speech. Referring diagnosis was incorrect in 35% patients. Postsclerotherapy and postexcision pain scores were mean (SD) 5 (1.26) and 4 (1) respectively. All patients had improvement in eating and speech with restoration of normal muscle function in mean (SD) 5.63 (1.2) weeks. Ninety-five percent patients were satisfied with their outlook. One patient had recurrence at 1 year follow-up. CONCLUSION: Surgical debulking with proper use of adjuvant procedure for vascular malformations of lip produces best functional and aesthetic results with minimal complications.

Comparison of Clinical Outcome of Facial Artery Myomucosal Flap and Tongue Flap for Closure of Large Anterior Palatal Fistulas.

Closure of large anterior palatal fistula has high recurrence rate. The objective of this study was to compare the clinical outcome of facial artery myomucosal flap (FAMM flap) and tongue flap used for closure of large anterior palatal fistula. This study was conducted from March 2008 to March 2014. Thirty-nine patients, aged 2 to 40 years, who had anterior palatal fistula 5 to 20 mm in width with associated alveolar cleft and repaired with either a tongue flap or FAMM flap were included. Patients were excluded if they had adequate local palatal tissue for closure, mid, posterior or multiple fistulae, fistula width >20 mm. Closure was performed in 2 layers. Turndown flap of oral mucoperiosteum was used to reconstruct nasal layer and oral layer was reconstructed with FAMM flap in 16 and tongue flap in 23 patients. Mean(SD) pain score was 3(1) and 7(1) in FAMM flap and tongue flap groups respectively with a P value <0.096. All patients in tongue flap group experienced difficulty in speaking and eating whereas in FAMM flap group 2 had eating problem and 2 experienced speech difficulty. Mean(SD) total operative times for FAMM flap and tongue flap were 155(38) and 242(10) minutes, respectively, P value <0.002. There was no difference for other complications and no recurrence at 1 year follow-up in both groups. The authors concluded that FAMM flap should be considered first choice for closure of large anterior palatal fistulas associated with alveolar cleft as it requires less total operative time and has less early postoperative complications.

Comparison of single intra operative versus an intra operative and two post operative injections of the triamcinolone after wedge excision of keloids of helix.

OBJECTIVE: To compare single intra-operative versus an intra-operative and two post-operative injections of triamcinolone after wedge excision of keloids of helix. METHODS: The randomised controlled trial was conducted at the King Edward Medical University, Lahore, from January, 2011, to March, 2014, and comprised female patients over 14 years of age presenting with post-piercing keloids of helix not treated previously by any means and amenable to wedge excision. The subjects were divided into Group A who were given a single intra-operative injection of triamcinolone, and Group B who had an intra-operative and two post-operative injections of triamcinolone. Extra-lesional wedge excision of keloids was done, followed by infiltration of flaps and wound base with 0.5-1cc of triamcinolone 40mg/cc. Group B patients were given additional injections of triamcinolone at 1st and 2nd monthly visits. Both groups were observed for the evidence of hypertrophy or complications. Development of hypertrophy within one year of completion of treatment was considered recurrence. RESULTS: The 70 patients in the study were divided into two equal groups of 35(50%) each. The mean age of Group A was 22.34±4.95 years and that of Group B was 22.88±4.22 years (p=0.624). The Mean size of the keloids was 2.54±0.516 cm(2) in Group A and 2.61±0.569 cm(2) in Group B (p=0.613). Recurrence rate in Group A was 3(8.5%) and 2(5.7%) in Group B (p= 0.64). The complication rate was 3(8.5%) in Group A and 8(22.8%) in Group B (p=0.10). CONCLUSIONS: Single injection of triamcinolone was as effective as three in reducing recurrence with less complication rate.

Diagnostic Accuracy of Blood Glucose Measurements in Detecting Venous Compromise in Flaps.

Due to limitations of the current methods for monitoring flap circulation, newer methods with better diagnostic accuracy are needed. A drop in blood glucose levels within flap is a simple method that can be widely used; however, this method has been examined only in small cohorts. The objective of this study was to determine the diagnostic accuracy of blood glucose measurements within flaps in early detection of venous compromise. We sampled 127 pedicled and free flaps, including replants, performed on patients between 12 and 60 years of age. Within flap blood glucose measurements were performed using pinprick and a blood glucose meter at 0, 6, 12, 24 and 48  hours after operation. Daily examination for clinical signs of venous compromise was used to determine flap viability for up to 7th day after operation. Of the 127 flaps, 76 (60%) were performed on men and the mean age ±â€Šstandard deviation of the patients was 35.8 ±â€Š12.1 years. A cut-off value of 62  mg/dL was determined using a receiver operating characteristic curve. Using this cut-off value, the sensitivity and positive predictive values of within flap blood glucose for determining venous compromise were 90% and 91%, respectively, whereas the specificity and negative predictive values were 78% and 76%, respectively. The overall diagnostic accuracy of within flap blood glucose was 87%. We conclude that blood glucose measurement within flap has acceptable diagnostic accuracy and should be used for early detection of venous compromise.

Effect of Time Interval Between Tumescent Local Anesthesia Infiltration and Start of Surgery on Operative Field Visibility in Hand Surgery Without Tourniquet.

PURPOSE: To determine the optimal time interval between tumescent local anesthesia infiltration and the start of hand surgery without a tourniquet for improved operative field visibility. METHODS: Patients aged 16 to 60 years who needed contracture release and tendon repair in the hand were enrolled from the outpatient clinic. Patients were randomized to 10-, 15-, or 25-minute intervals between tumescent anesthetic solution infiltration (0.18% lidocaine and 1:221,000 epinephrine) and the start of surgery. The end point of tumescence anesthetic infiltration was pale and firm skin. The surgical team was blinded to the time of anesthetic infiltration. At the completion of the procedure, the surgeon and the first assistant rated the operative field visibility as excellent, fair, or poor. We used logistic regression models without and with adjustment for confounding variables. RESULTS: Of the 75 patients enrolled in the study, 59 (79%) were males, 7 were randomized to 10-minute time intervals (further randomization was stopped after interim analysis found consistently poor operative field visibility), and 34 were randomized to the each of the 15- and 25-minute groups. Patients who were randomized to the 25-minute delay group had 29 times higher odds of having an excellent operative visual field than those randomized to the 15-minute delay group. After adjusting for age, sex, amount of tumescent solution infiltration, and duration of operation, the odds ratio remained highly significant. CONCLUSIONS: We found that an interval of 25 minutes provides vastly superior operative field visibility; 10-minute delay had the poorest results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.