Subcutaneous emphysema of the hand caused by the suction drain -- a case report.

Subcutaneous emphysema of the hand can be related to non-infectious causes and most commonly high-pressure injection injuries. Surgical emphysema of the hand is rare. We report a case of surgical emphysema of the dorsum of the hand following the excision of a dorsal wrist ganglion when the inserted suction drain did not work properly, accompanied by the inadvertent compression of the patient's body. Conservative management was adequate; oedema and emphysema subsided in several days.

Diclofenac and metamizol in postoperative analgesia in plastic surgery.

BACKGROUND: Postoperative pain relief after major surgery cannot be achieved with opioids alone in all patients without respiratory depression or other significant drawbacks. Modern medical practice, therefore, dictates the use of alternative analgesic agents as an adjunct or substitute to minimize the deleterious effects and to facilitate an earlier return to work and daily activities. Diclofenac and metamizol inhibit prostaglandin synthesis, thus attenuate the peripheral nociceptive sensitization caused by the surgical trauma. This investigation was conducted to determine the potency of diclofenac compared with metamizol in the control of postoperative pain after various plastic surgical operations under general anesthesia. METHODS: A multiple-dose, randomized, double-blind clinical trial composed of one hundred and sixty-six patients was conducted. Group M patients received 1 g intramuscular metamizol (every 8 hours) and Group D patients received 75 mg intramuscular diclofenac (every 12 hours). Additional analgesia requirements were recorded and meperidine was used as the complementary analgesic when needed. Pain was assessed by visual analogue scores. Platelet count and bleeding time analyses were performed preoperatively and on the first postoperative day. RESULTS: Metamizol decreased the additional analgesia requirement during the 18 hours following surgery. This was also associated with significantly lower pain scores. There was no significant difference between the patients receiving either metamizol or diclofenac in terms of pain scores, additional request for analgesia and frequency of side effects from the 18th until the 48th hour postoperatively. However, the use of diclofenac was associated with reduced side effects, though a reduction in platelet number and prolongation of bleeding time was noted in the majority of the patients receiving diclofenac. CONCLUSIONS: Metamizol is significantly superior to diclofenac for the reduction of postoperative pain after plastic surgery in the first 18 hours after plastic surgery procedures and reduces the need for additional analgesia.

The effect of carnitine on random-pattern flap survival in rats.

Carnitine is an endogenous cofactor involved in the transport of long-chain fatty acids into the mitochondria where they undergo beta-oxidation. Through another reaction, carnitine produces free coenzyme A and reduces the ratio of acetyl-coenzyme A to coenzyme A, thereby enhancing oxidative use of glucose, augmenting adenosine triphosphate synthesis, and reducing lactate production and acidosis. Because of its regulatory action on the energy flow from the different oxidative sources, especially under ischemic conditions, carnitine has been used in cardiovascular diseases such as coronary heart disease, congestive heart failure, peripheral vascular disease, dyslipidemia, diabetes, and chronic renal diseases with satisfactory results. A flap is also a relatively ischemic tissue and may obtain benefit from carnitine. To investigate this, 30 rats were divided into three groups of 10 animals: a control group and two carnitine-treated groups. Random dorsal skin flaps were elevated on the rats. In the control group, no pharmacologic agents were used. Of the two treated groups, group 1 was treated with 50 mg/kg/day carnitine for 1 week and group 2 was treated with 100 mg/kg/day carnitine for 1 week. The areas of flap necrosis were measured in each group. The median areas of flap necrosis of the groups were 12.55, 9.23, and 4.9 cm2, respectively. There was a statistically significant improvement of flap necrosis in carnitine-treated groups compared with the control group (group 2, p = 0.001; group 3, p = 0.000). Furthermore, there was less necrosis in the high-dose carnitine-treated group than the low-dose carnitine-treated group. As a conclusion, carnitine may have a dose-dependent effect to increase flap survival in random skin flaps.

Computed tomographic evaluation before cranial bone harvesting to avoid unexpected hazards during aesthetic procedures.

Nowadays, cranium is the preferred bone-graft donor site for facial aesthetic operations. Preoperative information about the quality of cranial bone, such as bone thickness or presence of the diplopic space, can be useful to minimize intracranial complications. This fact is neglected in reconstructive and aesthetic surgery. The aim of this study is to assess the reliability of Computed Tomography (CT) to determine cranial bone quality. Sixty-four cadaver parietal bones, the preferred site for bone-graft harvesting, were used in this study. In the first stage, posterior parietal bone thickness, which is accepted as the thickest part of cranium, was measured at specially determined points using a micrometer and the results were recorded. Bone thickness was then measured again in the same points with CT. The two methods were compared statistically. The measurements were not found to be statistically different. The similar values obtained with CT and micrometers suggest that CT can accurately and reliably determine cranial thickness. Preoperative CT can be a significant guide for the harvest of cranial bone grafts without any intracranial complications in aesthetic surgery.

Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications.

Temporoparietal fascia constitutes a very important structural unit from both an aesthetic and a reconstructive surgical point of view. A histologically supported anatomic study was conducted for the reappraisal of the anatomic relationships and clinical application potentials of the data obtained. Anatomy of the temporoparietal fascia was investigated on 20 sides from 10 cadavers. After dissections, necropsies were obtained to demonstrate histologic features of the temporoparietal fascia. The outer part of the temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) in the inferior border and with orbicularis oculi and frontalis muscles in the anterior border. Therefore, plication of the temporoparietal fascia can increase tightness of the SMAS, orbicularis oculi, and frontalis muscle in rhytidectomy. The frontal branches of facial nerve were noted to course parallel to the frontal branch of the superficial temporal artery, lying deeper to the temporoparietal fascia within the innominate fascia. In the view of these findings, conventional subfascial dissection, which is performed to protect frontal branches of the facial nerve, is not reasonable during the temporal part of rhytidectomy. Careful subcutaneous dissection just under the hair follicles is more appropriate to avoid nerve injury and also provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy with protection of the auriculotemporal nerve and the superficial temporal vessels. Furthermore, two layered structures of the temporoparietal fascia are very suitable to insert a framework into the temporoparietal fascia for ear reconstruction to eliminate some of the shortcomings of Brent's technique. A thin muscle layer was also noted within the outer part of the temporoparietal fascia below the temporal line; the term "temporoparietal myofascial flap" would, therefore, be more accurate than "temporoparietal fascial flap." Finally, the innominate fascia and the deep temporal fascia can be elevated with the two layers of the temporoparietal myofascial flap to obtain a well-vascularized, four-layered myofascial flap based on the superficial temporal vessels. This multilayered flap can be used to reconstruct all defects when fine, pliable, thin, multilayered flaps are required.

The dorsal branch of the digital nerve: an anatomic study and clinical applications.

The dorsal branch of the digital nerve was studied in 40 fingers from 8 cadavers. Our anatomic dissections showed that the dorsal branch of all digital nerves was constantly present. It arose from the digital nerve at the base of the proximal phalanx where digital vascular bifurcation usually occurred. The dorsal branch crossed the digital vascular bundle posteriorly and lay just above the extensor mechanism deeper to the dorsal-sensitive branches of the ulnar and radial nerves in the proximal and middle part of the proximal phalanx. The dorsal branch of the digital nerve supplies not only the dorsum of the middle phalanx, but also sends a branch to the dorsum of the proximal phalanx. Both dorsal branches should be used for maximal sensation while performing an innervated cross-finger flap. Furthermore, if only one digital nerve anastomosis is performed, a painful neuroma may develop from the unrepaired digital nerve stump. Therefore both of the transected digital nerves should be repaired. The dissections of the dorsal branches may be started proximally from distal palmar crease when any difficulties are encountered for nerve isolation. Nerve stumps of the dorsal branches should be placed in a deeper tissue plane and epineural sutures may be useful to prevent painful neuroma. This technique should be used in selected patients to gain maximal sensibility regarding the described points.

End-on-side microvascular anastomosis: an experimental study.

A new method, the end-on-side microanastomotic technique, is presented and also compared with the conventional end-to-side technique. The technique can be summarized as follows: The proximal end of the donor vessel is incised bilaterally at midlateral points. Thus it is separated into inferior and superior segments. These segments are placed to overlap the posterior and anterior walls of the recipient artery by using two vertical sutures. Two additional horizontal sutures are placed between the apexes of the midlateral incisions and the apexes of the arteriotomy on the recipient artery. Eventually the microanastomosis is totally completed with four sutures lying at the intramural position in the recipient artery. Twenty rabbits were equally divided into two groups. The femoral and the profunda femoris arteries were used bilaterally to investigate applicability of the end-on-side technique in the first 10 rabbits. Eighteen end-on-side anastomoses were observed to be patent in the first stage. Subsequently the end-on-side technique was compared with the conventional end-to-side technique in the other 10 rabbits. All anastomoses, both end on side and end to side, were patient. Four end-on-side microanastomoses were histologically evaluated. It was proved that the end-on-side technique is a feasible and experimentally reliable method.

A new approach for the treatment of recurrent large abdominal hernias: the overlap flap.

In this article we report a new technique for the treatment of recurrent large abdominal hernias and skin laxity: the overlap flap. This technique combines abdominoplasty with hernia repair. Obese patients with recurrent large abdominal hernias and skin laxity could benefit from this operation. This operation could not be performed in patients with a wide absence of the abdominal wall. A total of six patients were treated with this technique in our clinic. Follow-up of the patients has ranged from 1 to 4 years. Cosmetic results were excellent in all patients. No recurrence of the hernias has been observed in any of the patients. Two flaps are prepared; the lower one is deepithelialized, and it is used as an autogenous mesh in place of a prosthetic material to reinforce the abdominal wall, and the upper flap is prepared and overlapped on this lower one.

A new technique for distal hypospadias repair: advancement of a distally deepithelialized urethrocutaneous flap.

We report on a new modification technique and the latest results of a procedure for treating cases of distal hypospadias with minimal or no chordee called advancement of a distally deepithelialized urethrocutaneous flap. This procedure incorporates correction of chordee, mobilization of the urethrocutaneous flap, and advancement of the flap through a tunnel until it reaches the tip of the glans. A total of 30 children underwent treatment using this procedure in our clinic. Follow-up of the patients ranged from 2 months to 3 years. Cosmetic results were excellent in all the patients. Fistula formation has been observed in only one patient, possibly due to a surgical accident. This technique may only be applied in distal hypospadias patients with minimal or no chordee in whom the meatus is localized to the coronal level or 0.5 cm proximal to it. Patients with a short urethra or in whom the meatus is distally localized but with severe chordee are not candidates for this technique. In general, this technique is not applicable in patients with ventral penile curvature. We would like to emphasize that this repair technique allows for simple and safe dissection of the distal urethra composed of only mucosa without corpus spongiosum around it. This kind of distal urethra can be advanced easily to the tip of the glans penis with the help of the dermal component.