Levobupivacaine Consumption in Automated Intermittent Bolus in Ultrasound Guided Subparaneural Sciatic Nerve Catheters: A Prospective Double-Blind Randomized Trial.

PURPOSE: Continuous sciatic nerve blocks have proven benefits for postoperative analgesia after foot surgery. However, the optimal mode of administration remains a point of debate. Ultrasound guided subparaneural injection accelerates onset time and increases duration after a single shot sciatic nerve block. This double blind prospective randomized trial compares the 48-hour local anesthetic (LA) dose consumption of an automated intermittent bolus technique to a continuous infusion regimen in a subparaneural sciatic nerve catheter after hallux valgus surgery. PATIENTS AND METHODS: Patients scheduled for hallux valgus surgery were randomized to receive either a continuous infusion of levobupivacaine 0.125% at 5mL/h (group A) or an intermittent automated bolus of 9.8 mL every 2 hours with a background of 0.1 mL/h (group B), both with a PCA bolus of 6 mL and lockout of 30 minutes. The 48 hour LA consumption, PCA boluses, Numeric Rating Scale (NRS), satisfaction and return of normal sensation were recorded. RESULTS: Sixteen patients were excluded because of protocol violation or technical problems and 42 patients remained for analysis. The 48 hour ropivacaine consumption was higher in group A (293 ±60 mL) than group B (257±33 mL). The median and highest NRS scores and patient satisfaction were not statistically different between groups. Normal sensation returned after 75 ± 22 hours (group A) and 70 ± 17 hours (group B). CONCLUSION: Programmed bolus administration in subparaneural sciatic nerve catheters reduces LA consumption 48 hours after surgery with equal analgesia and patient satisfaction. Return of sensation is variable and can last more than 75 hours.

Earlobe Reduction with Minimally Visible Scars: The Sub-Antitragal Groove Technique.

BACKGROUND: Ptosis of the earlobe is a common consequence of ageing, defined as an unappealingly large free caudal segment of over 5 mm. It is therefore important to consider reduction as a complement to rhytidectomy in selected patients. Moreover, facelifting operations can result in disproportionate or poorly positioned earlobes. Current earlobe-reducing techniques can leave a scar on the free lateral edge causing notching or involve complex pattern excisions with limited resection capability and the risk of deformities. The presented technique, on the other hand, is versatile and easy to use, as it follows general geometric principles. METHODS: Excision of the designed area results in an earlobe flap which can be rotated in the excision defect. This results in ideal scar locations, situated at the sub-antitragal groove and at the cheek junction. The technique is adjustable, to incorporate potential piercing holes. RESULTS: This technique takes approximately 15 minutes per earlobe to complete. The resulting earlobes have undisturbed free borders. No vascularization-related flap problems were noted. CONCLUSIONS: This technique is a viable method for reducing the earlobe with minimally visible scars. 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 .

Modified one-stage dorsal-inlay buccal mucosa graft technique for ventral penile urethral and penile skin erosion: A step-by-step guide.

OBJECTIVE: To demonstrate the use of a modified single-stage technique for the repair of a ventral penile urethral erosion with involvement of the penile skin, as penile urethral erosion is a rare but potential complication of chronic indwelling catheterisation with a lack of available recommendations for reconstructive options. PATIENT AND METHODS: A 44-year-old male with paraplegia, neurogenic bladder dysfunction and chronic sacral decubitus, presented with a large mid-penile erosion of the ventral penile shaft and urethra, which was caused by chronic transurethral indwelling catheterisation while being hospitalised in an intensive care unit. The reconstruction involved a single-stage dorsal-inlay buccal mucosa graft urethroplasty (Asopa) in addition to the second stage of a two-stage urethroplasty. The urethroplasty as well as the buccal mucosa graft harvest were performed by a single team. RESULTS: The modified single-stage urethroplasty procedure had a duration of 158 min with a postoperative hospitalisation of 3 days. At 8-months follow-up, the lesion had fully healed and the patient was back on clean intermittent self-catheterisation with solifenacin 10 mg daily. No complications occurred postoperatively. CONCLUSION: The modified single-stage dorsal-inlay technique is a viable method for repairing ventral penile urethral erosion with involvement of penile skin.

The effects of advanced glycation end products (AGEs) on dermal wound healing and scar formation: a systematic review.

INTRODUCTION: With ageing, the skin gradually loses its youthful appearance and functions like wound healing and scar formation. The pathophysiological theory of Advanced Glycation End products (AGEs) has gained traction during the last decade. This review aims to document the influence of AGEs on the mechanical and physiologic properties of the skin, how they affect dermal wound healing and scar formation in high-AGE populations like elderly patients and diabetics, and potential therapeutic strategies. METHODS: This systematic literature study involved a structured search in Pubmed and Web of Science with qualitative analysis of 14 articles after a three-staged selection process with the use of in- and exclusion criteria. RESULTS: Overall, AGEs cause shortened, thinned, and disorganized collagen fibrils, consequently reducing elasticity and skin/scar thickness with increased contraction and delayed wound closure. Documented therapeutic strategies include dietary AGE restriction, sRAGE decoy receptors, aminoguanidine, RAGE-blocking antibodies, targeted therapy, thymosin ß4, anti-oxidant agents and gold nanoparticles, ethyl pyruvate, Gal-3 manipulation and metformin. DISCUSSION: With lack of evidence concerning scars, no definitive conclusions can yet be made about the role of AGEs on possible appearance or function of scar tissue. However, all results suggest that scars tend to be more rigid and contractile with persistent redness and reduced tendency towards hypertrophy as AGEs accumulate. CONCLUSION: Abundant evidence supports the pathologic role of AGEs in ageing and dermal wound healing and the effectiveness of possible therapeutic agents. More research is required to conclude its role in scar formation and scar therapy.