Incidence of the "Adrenaline Rush" and Vasovagal Response with Local Anesthetic Injection.

BACKGROUND: Many patients feel an "adrenaline rush" or a vasovagal reaction when injected with lidocaine and epinephrine during wide awake surgery. The incidence of these reactions is not well documented in the literature. METHODS: In total, 387 patients were prospectively injected with lidocaine and epinephrine for minor procedures without sedation between July 1, 2019 and November 1, 2020. A concentration of epinephrine with 1:100,000 in 2% lidocaine was injected, with most patients getting less than 20 mL of volume. RESULTS: Eight (2.2%) of the patients had adrenaline rush symptoms, which included nervousness, anxiety, tremors, shaky feelings, flushing, diaphoresis, light-headedness, tingling, and "heart racing." Seven patients (1.8%) experienced vasovagal responses, which included nausea, a feeling of being unwell, faint, or lightheaded, or had circumoral pallor. CONCLUSIONS: Patients run a low risk of feeling an adrenaline rush or vasovagal reaction when injected with lidocaine and epinephrine. Routinely advising patients that the adrenaline rush can happen, and that this is not an allergic reaction can be helpful to allay fear of the unknown and to prevent false allergy beliefs. Injecting patients lying down may decrease the incidence of vasovagal reactions by increasing cerebral blood flow with the advantage of gravity.

Preoperative and Postoperative Assessment of Rectus Abdominis Muscle Size and Function following DIEP Flap Surgery.

BACKGROUND: Prospective evaluation of rectus abdominis muscle function after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction is limited. Elimination of muscle harvest with this procedure is theoretically associated with preservation of rectus abdominis function and minimization of abdominal wall morbidity. In this study, the authors evaluate the change in rectus abdominis muscle size and function after DIEP flap surgery. METHODS: Patients undergoing unilateral DIEP flap surgery were recruited prospectively. Using computed tomography, the change in preoperative to postoperative rectus abdominis muscle size was compared between the operative side rectus abdominis muscle and the contralateral, nonoperative control rectus abdominis. Postoperative muscle integrity and contractility were evaluated using ultrasound by comparing the change in rectus abdominis muscle dimensions between contractile and relaxed states. The BREAST-Q was used to score patients' subjective satisfaction. Clinical and radiographic hernia rates were also calculated. RESULTS: Analysis of 26 paired rectus abdominis muscles revealed no significant change in muscle size from preoperative to postoperative values. Furthermore, dimensional change from contractile to relaxed states postoperatively was similar for paired operative and nonoperative rectus abdominis muscles. BREAST-Q scores indicated a high degree of satisfaction in abdominal well-being, breast satisfaction, and surgical experience domains. There were no clinical or radiographic abdominal wall hernias noted. CONCLUSIONS: The DIEP flap is an effective surgical procedure with minimal abdominal wall morbidity that is associated with no measurable loss in rectus abdominis size and contractile function postoperatively. Patients are highly satisfied with their abdominal function postoperatively using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The cranial orbital buttress technique for nonsyndromic unicoronal and metopic craniosynostosis.

OBJECT Current craniosynostosis procedures can result in complications due to absorbable plates and screws or other specialized expensive hardware. The authors propose the cranial orbital buttress (COB) technique of frontoorbital remodeling for metopic and unicoronal synostoses, wherein no plates or screws are used. They hypothesize that, with this technique, aesthetically acceptable outcomes for unicoronal and metopic synostosis can be achieved. In this article, they present this technique and compare the results with current frontoorbital remodeling practices. METHODS The authors conducted a retrospective chart review of cases in which patients with nonsyndromic unicoronal or metopic synostosis underwent cranio-orbital surgery at their institution from 1985 through 2009. Operative parameters, surgical variations, and complications were analyzed. The COB technique uses a 1-piece switch, hemiforeheads, or multiple pieces for forehead remodeling. The supraorbital bar is reconstructed in patients with metopic synostosis using a double wedge or greenstick fracture technique, and in patients with unicoronal synostosis a hinge procedure based on a 1.5-orbital osteotomy is used. The supraorbital bar is advanced and supported in place by bone graft(s) inserted at the lateral aspect(s) of the orbit(s) to form a buttress, with fixation done using absorbable sutures. RESULTS A total of 79 cases met the criteria for inclusion in the study. Twenty-nine patients had metopic synostosis, 3 had combined metopic and sagittal synostoses, and 47 had unicoronal synostosis. The patients' mean age at surgery was 11.4 ± 10.1 months and the mean operative time was 183.4 ± 41.0 minutes. The mean length of hospital stay was 3.7 ± 1.2 days. The mean blood loss was 150.0 ± 125.6 ml, and 33% of patients required a blood transfusion (mean volume 206.9 ± 102.3 ml). In metopic synostosis, hemiforeheads were used most often (24/29, 83%), and the supraorbital bar was remodeled using a bilateral intracranial orbital osteotomy followed by a double wedge modification (23/29, 79%) or a greenstick fracture (4/29 14%) for milder cases. Forehead remodeling for unicoronal synostosis was by a forehead switch (39/47, 83%) and the supraorbital bar was remodeled using a 1.5-orbital intracranial orbital osteotomy (34/47, 72%) such that the bar was advanced on the abnormal side and hinged at the midline of the normal orbit. Perioperative complications occurred in 19% of cases and included dural tears (16%), inconsequential subdural hematoma (1.3%), and nasal greenstick fracture (1.3%). The total reoperation rate was 7.6% (cranioplasties for irregular contours, 6.3%; scar revision, 1.3%). CONCLUSIONS The COB remodeling technique is simple and efficient, gives acceptable outcomes, and is less resource intensive than previous techniques reported in the literature.

Split calvarial bone grafting in patients less than 1 year of age: technical note and use in craniofacial surgery for craniosynostosis.

PURPOSE: The material of choice for filling cranial defects is autologous split calvarial bone. Up to now, the thin calvarial bone and lack of diploic space in very young children has led surgeons to believe that harvesting of split calvarial grafts can generally not be done under the age of 2 years. We describe a simple technique for successful harvesting of split cranial vault bone in infants less than 1 year of age. METHODS: This procedure involves squeezing the bone to shear the outer from the inner table, followed by the use of thin sharp osteotomes. This technique has been used most often in fronto-orbital advancement operations for coronal and metopic synostosis. RESULTS: In this series of ten such patients, there was no resorption of the split calvarial grafts. CONCLUSIONS: Splitting of the cranial vault bone can be performed on infants as young as 9 months with good results.