Narcotic Use for Acute Postoperative Pain Management in Mohs Micrographic Surgery Patients With End Stage Renal Disease: A Review of the Literature.

BACKGROUND: Uncontrolled acute postoperative pain presents a significant management challenge when opioids are used in patients with end-stage renal disease (ESRD). Currently, there is a lack of quality pharmacokinetic and pharmacodynamic data regarding opioid medication use in ESRD patients to optimize safe and effective management. OBJECTIVE: To review the published literature on pharmacologic evidence for and against the use of opioid medications for acute postoperative pain following Mohs micrographic surgery in ESRD patients. METHODS: A search of PubMed was conducted to identify articles on the pharmacokinetic and pharmacodynamic properties of opioid pain medications in ESRD patients through March 1, 2020. RESULTS: Seventy-five articles were reviewed. Limited data exist on opioids safe for use in ESRD and are mostly confined to small case series. Studies suggest tramadol and hydromorphone could be considered when indicated. Methadone may be a safe option, but should be reserved for treatment coordinated by a trained pain subspecialist. CONCLUSION: Randomized clinical trials are lacking. Studies that are available are not sufficient to perform a quantitative methodologic approach. Evidence supports the judicious use of postoperative opioid medications in ESRD patients at the lowest possible dose to achieve clinically meaningful improvement in pain and function.

Mechanical Strain of the Trilobed Transposition Flap in Artificial Skin Models: Pivotal Restraint Decreases With Decreasing Rotational Angles.

BACKGROUND: In transposition flaps, thicker tissue and higher degrees of rotation are associated with increased pivotal restraint; however, limited experimental data exist quantifying the degree to which these affect flap biomechanics. The use of artificial skin models in conjunction with digital image correlation technology allows for investigation into biomechanical properties of skin flaps. OBJECTIVE: To quantify the effects of tissue thickness and rotational angles on pivotal restraint within transposition flaps using artificial skin models. METHODS: Ninety degree bilobed and trilobed flaps were used to close defects in artificial skin models of increasing thicknesses. Digital image correlation was used to quantify strain. Quantitative and qualitative differences in strain were assessed in increasing flap thicknesses and between flap designs. RESULTS: Increasing flap thickness was associated with decreasing strain. In the bilobed flap, increasing thickness was associated with displacement of the flap pivot point away from the distal flap edge. Comparatively, lower angles of rotation in the trilobed flap were not associated with migration of the flap pivot point. CONCLUSION: Increased pivotal restraint observed in higher degrees of rotation is due to migration of the flap pivot point. This model supports the common practice of decreasing flap angles to compensate for pivotal restraint.

Mechanical Strain of the Nasal Bilobed Transposition Flap-Graduated Changes in Skin Thickness Superiorly Displace the Location of the Pivot Point.

BACKGROUND: The bilobed transposition flap recruits the relatively thinner and laxer skin of the nasal dorsum and sidewall to reconstruct defects of the more sebaceous nasal tip and alae. There have been no studies performed to quantify how the material properties of skin alter the bilobed flap's performance during nasal reconstruction. OBJECTIVE: To determine the effects of skin thickness and stiffness on bilobed flap mechanics to help guide flap design principles and optimize surgical outcomes. MATERIALS AND METHODS: Two-dimensional artificial silicone skin models of varying thickness were created. The bilobed flap was incised, transposed, and secured in standard fashion. Digital image correlation was used to translate model deformation and displacement into local stress and mechanical strain forces within the bilobed flap pedicle. RESULTS: Qualitatively, the center of rotation of the bilobed flap rotates superiorly up the flap pedicle as model skin thickness increased. CONCLUSION: Location of the bilobed flap's pivot point may be dependent on local tissue characteristics-oversizing of the primary lobe can be considered in stiff, immobile tissue such as highly sebaceous Zone II nasal skin.

Using Grafts and Granulation to Improve Nasal Repair.

Skin grafts offer a dynamic repair option for nasal defects of appropriate size, depth, and location. Granulation and grafting can successfully be used as stand-alone reconstructive options or in conjunction with flap repair. This article reviews suitable indications for graft and granulation use in nasal repair to achieve optimum functional and esthetic outcomes.

Interpolated Flaps.

Nasal reconstruction has been articulated in the literature since 700 B.C. when the earliest iteration of the forehead flap was described in the Indian medical treatise, the Sushruta Samhita. Since then it has evolved into the interpolated flap which has served as a powerful tool for facial reconstruction. The interpolated flap is constructed from nonadjacent donor tissue that has an inherent blood supply. It requires a multistaged approach and is best suited for reconstruction of large or deep defects of the nose. There are three types of interpolated flaps used for nasal reconstruction: the forehead, melolabial, and nasofacial interpolation flaps. The nose is the central feature of the human face and its placement is both aesthetic and functional. Any defects owing to accidental or iatrogenic trauma can cause physiologic and psychological injury to patients. This article aims to review the aforementioned flaps and give indications, contraindications, procedure details, and future directions of these flaps.

The use of passive visual stimuli to enhance compliance with handwashing in a perioperative setting.

BACKGROUND: To encourage handwashing, we analyzed the effect that a passive visual stimulus in the form of a picture of a set of eyes had on self-directed hand hygiene among health care staff. METHODS: This was a prospective, single-blind study using a repeated measure design. Four dispensers of alcohol foam located in positions identified as #1, #2, #3, and #4 were used to deliver a single uniform volume of alcohol foam in an automated fashion. Pictures of eyes were placed on dispensers #1 and #3 but not dispensers #2 and #4 for 1 time period. The visual stimulus was rotated with each study time period. At the end of each study period, the volumes dispensed were examined to determine if the visual stimulus had a statistically significant influence on the volume dispensed. RESULTS: There were a total of 6 time periods. The average volume dispensed in stations with eyes was 279 cc versus that in the stations without eyes, which was 246 cc, and this was a statistically significant difference (P = .009). CONCLUSION: The correct visual stimuli may enhance compliance with hand hygiene in health care settings.

Early excision and grafting, an alternative approach to the surgical management of large body surface area levamisole-adulterated cocaine induced skin necrosis.

Levamisole-adulterated cocaine as a cause of retiform purpura progressing to full-thickness skin necrosis was first documented in 2003 and currently comprises over 200 reported cases. Whereas, its presentation, pathophysiology, and diagnostic workup have been reasonably well-defined, only one publication has significantly detailed its surgical management. For this reason there exists a relative absence of data in comparison to its reported incidence to suggest a preferred treatment strategy. In the case mentioned, treatment emphasized delayed surgical intervention while awaiting lesion demarcation and the monitoring of autoantibodies. At our institution we offer an alternative approach and present the case of a 34 year old female who presented with 49% TBSA, levamisole-induced skin necrosis managed with early surgical excision and skin grafting. The patient presented three days following cocaine exposure with painful, purpura involving the ears, nose, buttocks, and bilateral lower extremities which quickly progressed to areas of full-thickness necrosis. Lab analysis demonstrated elevated p-ANCA and c-ANCA, as well as leukopenia, decreased C4 complement, and urinalysis positive for levamisole, corroborating the diagnosis. Contrasting the most thoroughly documented case in which the patient underwent first surgical excision on hospital day 36 and underwent 18 total excisions, our patient underwent first excision on hospital day 10 and received only one primary excision prior to definitive autografting. To our knowledge, this is the largest surface area surgically treated that did not result in surgical amputation or autoamputation of limbs or appendages, respectively. We contend that early excision and grafting provides optimal surgical management of this syndrome while avoiding the morbidity seen with delayed intervention.