Bilateral Ultrasound-Guided Erector Spinae Plane Block for Perioperative Analgesia in Breast Reduction Surgery: A Prospective Randomized and Controlled Trial.

BACKGROUND: Ultrasound-guided erector spinae plane block (ESPB) is an interfascial plane block used for analgesia of the chest and abdominal wall. This study aimed to evaluate the perioperative analgesic efficacy of bilateral single-shot ESPB at T5 vertebral level in breast reduction surgery. MATERIALS AND METHODS: Sixty adult female patients scheduled for breast reduction surgery were included and randomly allocated to two groups to receive either preoperative ESPB with a local anesthetic mixture of 10 mL 0.5% bupivacaine, 5 mL 2% lidocaine, and 5 mL saline, or sham block. Patients in both groups received intraoperative remifentanil infusion and, postoperatively, morphine via the patient-controlled analgesia (PCA) device. The primary outcome was 24-h total morphine consumption, and secondary outcomes included intraoperative opioid consumption, postoperative pain intensity, time to first PCA request, supplement analgesic requirements, functional recovery, patient satisfaction, length of hospital stay, and side effects and complications. RESULTS: The 24-h total morphine consumption was significantly lower in the ESPB group vs. the sham group (mean ± SD, 6.7 ± 3.9, and 13.9 ± 5.7 mg, respectively, p < 0.001). Compared with sham block, ESPB reduced pain scores, intraoperative opioid consumption, supplement analgesic requirements, delayed time to first PCA request, and improved functional recovery and patient satisfaction. CONCLUSION: In breast reduction surgery, preoperative single-shot ESPB reduces perioperative opioid consumption and provides adequate pain relief within 24 h postoperatively compared to systemic analgesics alone. TRIAL REGISTRATION NUMBER: NCT03621345 LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lateral arm perforator flap as an island advancement flap for posterior elbow soft-tissue reconstruction.

Many flap designs for coverage of soft-tissue defects of the posterior elbow have been reported, and the lateral arm flap is considered reliable. With the advantages of less donor site morbidity and preservation of the continuity of the source artery, perforator flaps have taken the place of lateral arm flap recently. The lateral arm perforator flaps for elbow soft-tissue coverage have a propeller design. In this report, we describe a case of posterior elbow defect that was reconstructed with posterior radial collateral artery perforator island advancement flap. Lateral arm perforator island advancement flap is a good alternative for a propeller flap for coverage of soft-tissue defects of the posterior elbow.

The healing effect of pulsed magnetic field on burn wounds.

A burn is one of the most difficult injuries people can face.The primary pathology is coagulation necrosis resulting from tissue damage.Many wound care products have been developed to be used in situations such as the poor general condition of the patient and lack of solid area to be grafted. However, the high costs of these products make their use complicated.In this study, the effect of PEMF on cutaneous wound healing in an animal burn model was evaluated and the dose and duration of the magnetic field should be discussed for this effect to occur. Animals were divided into five groups including eight each (n = 40) (Groups 1, 2, 3, 4, 5).Group 1 was the control group; received no treatment after second-degree burn wound. Group 2 received daily wound care with saline. Group 3 received daily wound care with pomade containing mupirocin. Group 4 received Pulsed Electromagnetic Field signal for 60 min (1.5 m T and 40 Hz for seven days and Group 5 also received PEMF signal for 60 min the same frequency and intensity for14 days. Microscopically, second-degree burn wounds were successfully detected in all rats. Histopathological examination results in no significant difference between groups in neutrophil infiltration. The difference between the groups in vascularization was statistically significant between Group II and Group V (p < 0.001) and between Group I and Group V (p = 0.005) Epithelialization was present in 75% of the rats in Group V, while no epithelialization was observed in any of the other groups. In conclusion, we observed a significant improvement in the stasis zone of the group receiving Pulsed Electromagnetic Field for two weeks.

Reconstruction of Achilles region defects: A single-centre experience.

BACKGROUND: Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to the use of free flaps. The aim of this study was to discuss reconstruction options and to help the surgeon to select reliable approach to achieve favourable outcomes. METHOD: In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single centre. RESULTS: Reconstructions were performed with secondary healing (n = 2), negative pressure wound therapy and skin grafting (n = 2), free flaps (n = 6) and local and distant flaps (n = 4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting. CONCLUSION: Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. The use of special digital imaging techniques facilitates flap surgery and helps minimise the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Super-thin free flaps offer a distinct advantage in skillful hands. The use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favourable outcomes.

Reconstruction of firearm and blast injuries in Syrian war refugees.

BACKGROUND: War injuries differ from other injuries owing to the large tissue defects they cause and their high risk of contamination. As fragments scattered by high-energy firearms and explosives cause serious composite tissue damage, repair of such injuries is difficult and requires a long treatment period. We discuss the treatment methods used for injured Syrian War refugees admitted to our clinic and present the most effective repair methods for war-related tissue defects for each region of the body. METHODS: A total of 61 patients treated between June 2012 and April 2015 were retrospectively evaluated in terms of age, gender, duration of hospitalisation, injury site and repair method employed. The patients were grouped by region injured (head/neck, extremities and trunk). RESULTS: The female-to-male ratio of the patients was 16/45, and their mean age was 25.2 (range, 3-51) years. Twenty-two patients were under the age of 18. The mean duration of hospitalisation was 28.5 days. A total of 130 operations were performed on the patients, including debridement and revisions. Repairs were conducted with free flaps in 17 patients (6 on the head/neck region, 11 on extremities) and with pedicle flaps in 28 patients (11 on the head/neck region, 12 on extremities, 5 on the trunk). Two patients experienced flap loss without other complications, and other patients experienced complications including bleeding, infection, flap detachment, hematoma and seroma. CONCLUSIONS: War injuries cause tissue damage of a composite and extensive nature. Most affect the extremities, followed by the head/neck and trunk regions. They are primarily sustained by the young population, not usually easy to treat, and require long hospitalisation periods. A variety of methods may be preferred to treat these injuries.

A cross flow-through pedicle free latissimus dorsi flap for high voltage electrical burns.

BACKGROUND: The management of a high voltage electrical injury and lower limb salvage remains a challenging task for plastic surgeons. Reconstruction with flaps is often the only alternative to limb amputation. The purpose of this study was to present a cross flow-through pedicle free latissimus dorsi muscle flap for the salvage of severely traumatized lower limbs perfused by one remaining vessel (a single vessel lower limb) in high voltage electrical injuries. METHODS: In this retrospective study, between 2000 and 2014, six men underwent cross-leg free Latissimus dorsi muscle flap operations for limb salvage. They had soft tissue lower leg defects due to high voltage electrical injuries. Their medical records were retrospectively reviewed. All had only one artery that perfused the leg. Free pedicled thoracodorsal artery latissimus dorsi flaps were harvested and connected to the contralateral posterior tibial artery. RESULTS: All defects were successfully covered. No flap loss or major amputation occurred during follow-up (mean; 5.9 years). A computerized tomography angiogram showed intact vessel continuity in the recipient vascular system. The patients were able to walk without any apparatus or assistance after long term follow-up. CONCLUSION: We recommend that the cross flow-through pedicle free muscle flap should be considered as a salvage procedure for single vessel lower extremities resulting from high voltage electrical burns. Extremity perfusion was not compromised by this procedure.

Outcomes of Tissue Expander Application for Scalp Reconstruction in Extensive Aplasia Cutis Congenita.

INTRODUCTION: Aplasia cutis congenita (ACC) is a rare congenital disorder. The purpose of this study was to present outcomes of tissue expander application for scalp reconstruction in extensive ACC. PATIENT/METHODS: In this retrospective study, medical records were reviewed for six patients who underwent serial tissue expander application for scalp reconstruction in ACC between 2000 and 2015. Patient average age was 14.5 (range, 4-25 years). One of the six cases had frontal bone defect, the others had bone and soft tissue defect at the vertex. In the newborn period, all patients have been managed by split-thickness skin grafts without cranioplasty procedures. After grafting and calvarial regeneration, one (or more) sessions of tissue expanders and scalp flap applications were performed for alopecia and soft tissue correction. Radiologic and clinical examination was performed for complications and outcomes. RESULTS: Computerized tomography showed intact calvarium with patchy hyperostosis in all patients. The mean size of grafted areas was 69.5 cm(2) (range, 32-148.5 cm(2)). Minimal distal flap necrosis (6 × 1 cm) was observed in one patient. Serial scalp tissue expansion was performed with at least one session in a 1-year interval. One expander was extracted due to exposition and infection. No total flap losses and no calvarial defects were observed during follow-up (mean; 8.6 years). Clinical examination revealed acceptable cosmetic results in all patients. CONCLUSION: We advocate late expander scalp reconstruction for management of extensive ACC cases. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Total or Near-Total Lower Eyelid Defect Reconstruction Using Malar Myocutaneous Bridge and Nasojugal Flaps and Septal Chondromucosal Graft.

PURPOSE: The purpose of this study is to repair total or near-total lower eyelid defects by single-staged operative technique. METHODS: The procedure was performed on 7 referred patients who had a total or near-total lower eyelid defects after tumor extirpation or trauma. Patients ages were between 13 and 67 years (average, 46.5). Defects were repaired by simultaneous reconstruction of anterior and posterior lamellae using a bipedicled malar myocutaneous bridge flap, a nasojugal transposition flap, and a septal chondromucosal graft in combination. RESULTS: Patients were followed up for 12 to 24 months (average, 18 months). No necrosis, hematoma, or infection was observed in flaps, and no recurrence was observed in any patients. Mild scleral show was observed at postoperative 12 months in 2 cases. CONCLUSIONS: As an addition to classical methods, the present novel single-staged surgical procedure with the malar myocutaneous bridge flap, nasojugal transposition flap, and septal chondromucosal graft combination provides anatomical, functional, and stable reconstruction for total or near-total lower eyelid defects.