An Unusual Presentation of Blastomycosis.

INTRODUCTION: Blastomycosis is a rare pyogranulomatous infection that most commonly involves the lungs and sometimes the skin. Other manifestations are much less common. Diagnosis relies on biopsy, histopathology, and culture of suspicious lesions. CASE PRESENTATION: In this case, a healthy 42-year-old male from Wisconsin presented to the emergency department with a chief complaint of 2 weeks of knee pain without a clear mechanism of injury. Upon further examination, he was found to have lesions on his abdomen, which he had first noticed over 3 years prior and had been treated with antibiotics as cellulitis for nearly 18 months. Biopsy of these lesions was consistent with blastomycosis infection, and further work-up and examination was notable for brain and laryngeal lesions without any pulmonary involvement. Intense anti-fungal treatment was immediately initiated with dramatic improvement in his symptoms. DISCUSSION: This case highlights the importance of a thorough physical exam and consideration of rare infections in cases without clear answers. To our knowledge, this is the first published example of a blastomycosis infection involving brain, laryngeal, skin, and knee lesions without pulmonary infection.

A Comprehensive Review of the Genetic and Epigenetic Contributions to the Development of Fibromyalgia.

This narrative review summarizes the current knowledge of the genetic and epigenetic contributions to the development of fibromyalgia (FM). Although there is no single gene that results in the development of FM, this study reveals that certain polymorphisms in genes involved in the catecholaminergic pathway, the serotonergic pathway, pain processing, oxidative stress, and inflammation may influence susceptibility to FM and the severity of its symptoms. Furthermore, epigenetic changes at the DNA level may lead to the development of FM. Likewise, microRNAs may impact the expression of certain proteins that lead to the worsening of FM-associated symptoms.

Power-assisted Liposuction and a Single Incision Pull-through Technique for Top Surgery: A Case Report.

Various treatment approaches exist for female-to-male subcutaneous mastectomy, also known as "top surgery." The most commonly performed techniques for patients with decreased volume of breast tissue, no ptosis, and good skin elasticity continue to involve areolar or periareolar incision. Here, we report a case of a 17-year-old patient who underwent top surgery performed through power-assisted liposuction and a non-areolar single-incision "pull-through" technique. Operative management included initial liposuction for contouring of adipose tissue. Surgical subcision of excess breast tissue adherent to the subdermal plane was then performed and removed with a grasp-and-pull motion using the pull-through technique. We obtained a favorable result with low scar burden, preserved nipple sensation, and no nipple contracture. No complications were reported. This procedure is limited for patients with small breast size (A cup, <100 grams of glandular tissue per side), minimal to no ptosis, appropriate nipple size and position, soft fibroglandular tissue, and good skin elasticity.

Management of Congenital Auricular Anomalies.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe normal ear anatomy and development, and evaluate the patient's ears for differences in shape, size, prominence, and symmetry. 2. Identify common congenital ear deformities, including prominent ear, macrotia, Stahl ear, cryptotia, constricted ear, and lobule anomalies. 3. Describe both early nonoperative management and operative techniques for correction of these ear deformities. 4. Be aware of advantages and disadvantages of common and emerging techniques for correction of pediatric ear deformities. SUMMARY: Whereas severe ear malformations such as microtia/anotia are rare, other ear deformities, such as prominent ear, Stahl ear, and cryptotia, are common. Although these ear deformities result in minimal physiologic morbidity, their psychological and cosmetic impact can be significant. Identifying these common deformities and understanding how they differ from normal ear anatomy is critical to their management. In cases where a deformity is identified in neonatal life, ear molding may obviate the need for surgery. Although various surgical techniques have been described for correction of common ear deformities, the surgeon should follow a careful stepwise approach to address the auricular deformity or deformities present. By using such an approach, complications may be minimized and predictable aesthetic outcomes achieved.

Effective Rejuvenation with Hyaluronic Acid Fillers: Current Advanced Concepts.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Process several patient-specific factors before reaching an optimal treatment strategy with appreciation for facial balance. 2. Define the advantages and disadvantages of various hyaluronic acid preparations and delivery techniques, to achieve a specific goal. 3. Perform advanced facial rejuvenation techniques adapted to each facial zone, combining safety considerations. 4. Prevent and treat complications caused by inadvertent intraarterial injections of hyaluronic acid. SUMMARY: The growing sophistication and diversity of modern hyaluronic acid fillers combined with an increased understanding of various delivery techniques has allowed injectable filler rejuvenation to become a customizable instrument offering a variety of different ways to improve the face: volume restoration, contouring, balancing, and feature positioning/shaping-beyond simply fading skin creases. As more advanced applications for hyaluronic acid facial rejuvenation are incorporated into practice, an increased understanding of injection anatomy is important to optimize patient safety.

Evidence-based Sterility: The Evolving Role of Field Sterility in Skin and Minor Hand Surgery.

Field sterility is commonly used for skin and minor hand surgery performed in the ambulatory setting. Surgical site infection (SSI) rates are similar for these same procedures when performed in the main operating room (OR). In this paper, we aim to look at both current evidence and common sense logic supporting the use of some of the techniques and apparel designed to prevent SSI. This is a literature review of the evidence behind the ability of gloves, masks, gowns, drapes, head covers, footwear, and ventilation systems to prevent SSIs. We used MEDLINE, EMBASE, and PubMed and included literature from the inception of each database up to March 2019. We could not find substantial evidence to support the use of main OR sterility practices such as head covers, gowns, full patient draping, laminar airflow, and footwear to reduce SSIs in skin and minor hand surgery. Field sterility in ambulatory minor procedure rooms outside the main OR is appropriate for most skin and minor hand surgery procedures. SSIs in these procedures are easily treatable with minimal patient morbidity and do not justify the cost and waste associated with the use of main OR sterility.

Wide-awake Anesthesia No Tourniquet Trapeziometacarpal Joint Prosthesis Implantation.

Wide awake local anesthesia no tourniquet (WALANT) hand surgery is a rapidly growing in popularity. WALANT has been used by hand surgeons when operating on bones, tendons, ligaments, nerve entrapments. We offer a case report of the first case in the literature describing WALANT technique when performing trapeziometacarpal joint arthroplasty with prosthesis implantation. We offer technical points on how to perform this procedure and the advantages that are associated with using WALANT for prosthesis arthroplasty.

How Many Trigger Fingers Resolve Spontaneously Without Any Treatment?

INTRODUCTION: There is very little information in the literature evaluating the natural history of adult trigger fingers and their rate of spontaneous resolution over time. METHODS: A consecutive case series of patients with trigger finger was generated. For each patient, we recorded whether the patient's disease resolved from either no treatment versus active treatment options and over what time period. RESULTS: Three hundred forty-three patients with trigger finger were included in the study. Fifty-two percent of patients resolved without any treatment whatsoever after waiting a mean (and median) of 8 months from initial consultation. The thumb was the most frequent digit to resolve without treatment (72%). CONCLUSIONS: We found that just over half of patients with trigger fingers who are referred to our office resolve spontaneously without any intervention.

HISTORIQUE: Très peu de publications portent sur l'évolution naturelle des doigts à ressort chez les adultes et sur leur taux de résolution spontanée au fil du temps. MÉTHODOLOGIE: Les chercheurs ont produit une série de cas consécutifs de patients ayant un doigt à ressort. Pour chaque patient, ils ont vérifié si le problème s'était résolu sans traitement ou après un traitement actif ainsi que le laps de temps nécessaire pour parvenir à ce résultat. RÉSULTATS: Au total, 343 patients ayant un doigt à ressort ont participé à l'étude. Le problème s'est résolu sans traitement chez 52 % des patients au bout d'une période moyenne (et médiane) de huit mois après la première consultation. C'est le pouce qui guérissait le plus souvent sans traitement (72 %). CONCLUSION: Les chercheurs ont découvert qu'un peu plus de la moitié des patients ayant un doigt à ressort qui sont dirigés vers leur bureau guérissent spontanément sans intervention.

Wide Awake Trapeziectomy for Thumb Basal Joint Arthritis.

Supplemental Digital Content is available in the text.

Wide Awake Open Reduction of Irreducible Metacarpal Phalangeal Joint Dislocations.

Supplemental Digital Content is available in the text.

Minimal Pain Local Anesthetic Injection with Blunt Tipped Cannula for Wide Awake Upper Blepharoplasty.

Supplemental Digital Content is available in the text.

Cases of Early Infectious Flexor Tenosynovitis Treated Non-Surgically With Antibiotics, Immobilization, and Elevation.

BACKGROUND: Early infectious flexor tenosynovitis has been treated with urgent surgery by most surgeons since Bunnell wrote the first textbook of hand surgery in 1945. Some surgeons have good experience with non-surgical management of early presenting disease in some cases. METHODS: This retrospective chart review included 12 inpatients with early infectious flexor synovitis who received conservative treatment with antibiotics, immobilization, and elevation without surgical drainage. RESULTS: The mean time to resolution of infective symptoms for the 12 patients was 5 days (range: 2-11 days) for those receiving conservative management. Half of them required hand therapy. Eight of the 12 patients had good documentation of a full return of hand function. CONCLUSIONS: In some patients with early infectious flexor synovitis, urgent surgery may not be required. We present a brief synopsis of 12 such cases.

HISTORIQUE: La plupart des chirurgiens opèrent d'urgence les ténosynovites infectieuses précoces des fléchisseurs depuis que Bunnell a rédigé le premier manuel sur les chirurgies de la main en 1945. Certains chirurgiens possèdent une bonne expérience de la prise en charge non chirurgicale de certains cas à présentation précoce. MÉTHODOLOGIE: La présente analyse rétrospective des dossiers médicaux portait sur 12 patients hospitalisés à cause d'une synovite infectieuse précoce des fléchisseurs qui avaient reçu un traitement prudent au moyen d'antibiotiques, d'une immobilisation et d'une élévation, sans drainage chirurgical. RÉSULTATS: La période moyenne jusqu'à la résolution des symptômes des 12 patients ainsi traités était de cinq jours (plage de deux à 11 jours). La moitié d'entre eux ont dû subir une chirurgie de la main. Huit des 12 patients présentaient une reprise complète de la fonction de la main bien étayée. CONCLUSIONS: Chez certains patients atteints d'une synovite infectieuse précoce des fléchisseurs, la chirurgie d'urgence n'est pas nécessaire. Les auteurs présentent un synopsis de ces 12 cas.

Matching the Implant to the Breast: A Systematic Review of Implant Size Selection Systems for Breast Augmentation.

BACKGROUND: For primary breast augmentation, several implant selection systems have been described to guide the surgeon with choosing from a variety of manufactured implant dimensions and properties. Controversy exists regarding the most efficacious method of selecting an appropriate implant size that best matches the patient's breast. METHODS: The goal of this systematic review was to provide a comprehensive list of documented implant size selection systems, and to critically evaluate them. Implant size selection systems were grouped into categories based on selection principles. Articles were evaluated based on reported outcome measures and methodologic quality. RESULTS: Thirty-three implant size selection systems were included in the final analysis. Only 12 percent of articles (four of 33) reported clinical outcomes that could be compared to accepted literature values or industry standards. Articles that described tissue-based planning systems, which use clinical guidelines to determine the optimal patient-specific implant dimensions, were of highest methodologic quality using the Methodological Index for Non-Randomised Studies scale, when compared to systems that used breast "dimensional" analyses that stress tissues to the desire of the patient and/or surgeon, and compared to systems that did not use breast measurement (means ± SD, 6.0 ± 1.4, 1.4 ± 2.3, and 0.0 ± 0.0, respectively). CONCLUSIONS: There is some evidence to support tissue-based planning as a superior approach to implant size selection planning; studies that used tissue-based planning reported lower reoperation rates compared with industry standards and accepted literature values. The authors offer several suggestions on how to improve the methodologic quality of future studies describing new implant selection systems.

Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet.

BACKGROUND: In our experience, for all surgeries in the hand, the optimal epinephrine effect from local anesthesia-producing maximal vasoconstriction and visualization-is achieved by waiting significantly longer than the traditionally quoted 7 min from the time of injection. METHODS: In this prospective comparative study, healthy patients undergoing unilateral carpal tunnel surgery waited either 7 min or roughly 30 min, between the time of injection of 1 % lidocaine with 1:100,000 epinephrine and the time of incision. A standardized incision was made through dermis and into the subcutaneous tissue followed by exactly 60 s of measuring the quantity of blood loss using sterile micropipettes. RESULTS: There was a statistically significant reduction in the mean quantity of bleeding in the group that waited roughly 30 min after injection and before incision compared to the group that waited only 7 min (95 % confidence intervals of 0.06 + -0.03 ml/cm of incision, compared to 0.17 + -0.08 ml/cm, respectively) (P = 0.03). CONCLUSIONS: Waiting roughly 30 min after injection of local anesthesia with epinephrine as oppose to the traditionally taught 7 min, achieves an optimal epinephrine effect and vasoconstriction. In the hand, this will result in roughly a threefold reduction in bleeding-making wide awake local anesthesia without tourniquet (WALANT) possible. This knowledge has allowed our team to expand the hand procedures that we can offer using WALANT. The benefits of WALANT hand surgery include reduced cost and waste, improved patient safety, and the ability to perform active intraoperative movement examinations.

Closed Microfracture Technique for Surgical Correction of Inferior Turbinate Hypertrophy in Rhinoplasty: Safety and Technical Considerations.

An abundance of surgical procedures are in use for the management of inferior turbinate hypertrophy in rhinoplasty patients. An ideal treatment approach is elusive, given the variability of patient presentation regarding obstructive nasal airway, significant complications associated with techniques that cause mucosal trauma, and the high recurrence rates associated with more conservative techniques. In an effort to improve patient safety, the authors describe a conservative technique-the closed microfracture-that provides an effective functional airway improvement and minimal to no complications. The authors propose a treatment approach for enlarged inferior turbinates based on turbinate subtype.

Inexpensive diffuse reflectance spectroscopy system for measuring changes in tissue optical properties.

The measurement of changes in blood volume in tissue is important for monitoring the effects of a wide range of therapeutic interventions, from radiation therapy to skin-flap transplants. Many systems available for purchase are either expensive or difficult to use, limiting their utility in the clinical setting. A low-cost system, capable of measuring changes in tissue blood volume via diffuse reflectance spectroscopy is presented. The system consists of an integrating sphere coupled via optical fibers to a broadband light source and a spectrometer. Validation data are presented to illustrate the accuracy and reproducibility of the system. The validity and utility of this in vivo system were demonstrated in a skin blanching/reddening experiment using epinephrine and lidocaine, and in a study measuring the severity of radiation-induced erythema during radiation therapy.

A review of hydrofluoric acid burn management.

Hydrofluoric acid (HF) causes a unique chemical burn. Much of the current treatment knowledge of HF burns is derived from case reports, small case series, animal studies and anecdotal evidence. The management can be challenging because clinical presentation and severity of these burns vary widely. Plastic surgeons managing burn patients must have a basic understanding of the pathophysiology, the range of severity in presentation and the current treatment options available for HF burns. The present article reviews the current understanding of the pathophysiology and systemic effects associated with severe HF burns. Furthermore, it distinguishes between minor and life-threatening HF burns and describes several of the basic techniques that are available to treat patients with HF burns.

L'acide fluorhydrique (AF) provoque une brûlure chimique bien particulière. La plus grande partie des connaissances actuelles sur les brûlures à l'AF sont dérivées de rapports de cas, de petites séries de cas, d'études sur des animaux et d'observations isolées. La prise en charge peut être difficile, car la présentation clinique et la gravité des brûlures sont très variées. Les plasticiens qui traitent les patients brûlés doivent posséder des connaissances de base sur la physiopathologie, les divers degrés de gravité de présentation et les possibilités thérapeutiques offertes pour soigner les brûlures à l'AF.Le présent article contient une analyse des connaissances sur la physiopathologie et les effets systémiques des graves brûlures à l'AF. Il fait également la distinction entre les brûlures à l'AF mineures et celles au potentiel fatal et contient une description de quelques-unes des techniques de base offertes pour traiter les patients ayant des brûlures à l'AF.

Acute generalized exanthematous pustulosis induced by hydroxychloroquine: first case report in Canada and review of the literature.

BACKGROUND: Acute generalized exanthematous pustulosis (AGEP) is a rare drug eruption presenting with an acute, extensive formation of nonfollicular sterile pustules on an erythematous and edematous base. Typically, the rash is accompanied by fever and leukocytosis, with spontaneous resolution in < 15 days. The incidence of AGEP is estimated at one to five cases per million people per year. Only 18% of these are from nonantibiotics. Hydroxychloroquine (HCQ) is an antimalarial agent that is also used to treat various dermatologic and rheumatologic conditions. OBJECTIVE: We report the first observation in Canada of a patient with AGEP induced by HCQ. METHODS AND RESULTS: AGEP was diagnosed in a 48-year-old female who had been taking HCQ for 2 weeks and then developed a diffuse erythematous and edematous pustular eruption. Clinical and pathologic findings were consistent with a diagnosis of AGEP. The patient was treated with steroids and supportive measures. The rash resolved after 18 days and a complicated course in hospital. CONCLUSION: AGEP is a rare drug eruption, usually to antibiotics. We report the first case in Canada of AGEP as an adverse reaction to HCQ. Clinicians should keep in mind the possibility of this severe skin eruption.

Optimal time delay between epinephrine injection and incision to minimize bleeding.

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.