Ideal timing of surgery for acute uncomplicated appendicitis.

BACKGROUND: Early surgery for appendicitis is thought to avoid complications associated with appendiceal rupture. AIMS: This study was to evaluate the effect of timing of surgery on complications, length of stay (LOS) and cost in patients undergoing appendectomy. MATERIALS AND METHODS: Retrospective review of 396 patients with appendectomies from January 1, 2005 to December 31, 2007 was performed. Demographic data, time of presentation, physical findings, diagnostic data, operating room times, LOS, cost and complications were collected. Patients were divided into 4 groups based on time from presentation to appendectomy. RESULTS: Pathology confirmed appendicitis in 354 (89%) patients. Most patients (90%) had surgery within 18 h of presentation. Timing of surgery did not affect the incidence of purulent peritonitis (P = 0.883), abscess (P = 0.841) or perforation (P = 0.464). LOS was significantly shorter for patients with emergency department registration to operating room times less than 18 h (P < 0.0001). Costs were significantly higher for patients with times to operating room greater than 18 h (P < 0.001). CONCLUSION: Timing of surgery did not affect the incidence of complications or perforated appendicitis. However, delay in surgical consultation and surgery are associated with increased LOS and increased hospital costs. The optimal timing of appendectomy for uncomplicated acute appendicitis appears to be within 18 h of emergency department presentation.

Prospective randomized comparison of onabotulinumtoxinA (Botox) and abobotulinumtoxinA (Dysport) in the treatment of forehead, glabellar, and periorbital wrinkles.

BACKGROUND: There are several commercially available neurotoxins to improve facial aesthetics, but few prospective, randomized trials have been conducted without commercial support to compare these agents. OBJECTIVES: The authors present the results of a study examining and comparing the effects of onabotulinumtoxinA (BoNT-ONA; Botox, Allergan, Inc., Irvine, California) and abobotulinumtoxinA (BoNT-ABO; Dysport, Ipsen Ltd, Slough, UK). METHODS: The authors enrolled 53 patients in a prospective, randomized trial in which each patient received a dose of BoNT-ONA on one side of the upper face and BoNT-ABO on the other. The effects of each agent were monitored and recorded over 150 days according to each patient's ability to elevate the brow, wrinkle count (as measured by the Visia system; Canfield Imaging Systems, Fairfield, New Jersey), and assessment of Fitzpatrick wrinkle scale rankings by blinded graders. RESULTS: Results showed no statistically significant differences between the two agents. Both agents yielded measurable improvements on wrinkles of the upper face at 150 days. CONCLUSIONS: At the current pricing of the agents, BoNT-ABO offers a significant cost savings over BoNT-ONA, with a comparable efficacy. The effect of both drugs appears to be more prolonged than indicated in the current manufacturer guidelines.

Posterolateral skull base reconstruction using the supraclavicular artery island flap.

The supraclavicular artery island (SAI) flap is a viable fasciocutaneous option for the reconstruction of head and neck defects. Although authors have reported success using SAI flaps for various reconstructive indications, concerns of a tenuous blood supply and distal ischemia have previously limited its use in the posterolateral skull base. This case series reports the outcomes of 5 consecutive patients receiving SAI flaps for posterolateral skull base reconstruction. All flaps were harvested in less than 1 hour with primary closure of all donor sites. A single patient developed superficial necrosis of the distal flap, which was repaired with a full-thickness skin graft. There were no other complications, and no donor site morbidity was observed. The SAI flap is an excellent option for the reconstruction of posterolateral skull base defects. The close color match, easy harvest within 1 hour, lack of microsurgical anastomosis, and absence of donor site morbidity support its continued utilization.

Outpatient abdominoplasty facilitated by rib blocks.

BACKGROUND: Striving to increase patient comfort and feasibility of performing abdominoplasties as outpatient procedures, investigators have been exploring alternative methods of anesthesia to safely avoid general anesthesia. These techniques may result in decreased narcotic administration, and decreased postoperative nausea and vomiting. The authors have added the use of preoperative local anesthesia rib blocks with sedation to replace general anesthesia in abdominoplasties. METHODS: All cases of abdominoplasty performed by the senior author (B.M.M.) were reviewed from 1999 to 2006 and divided into two groups. Group 1 was composed of 39 operations performed using general anesthesia. Group 2 was composed of 29 operations performed using rib blocks placed by the surgeon and supplemented by intravenous sedation. Chart review collected data on time in the operating and recovery rooms, use of narcotics and antiemetics, frequency of postoperative nausea and vomiting, and patient-reported pain. Possible confounding factors, additional procedures, anesthetic and surgical complications, and the need for hospitalization were also recorded. Statistical analysis with two-tailed Mann-Whitney and chi-square testing was used to reject the null hypothesis when comparing the two groups. RESULTS: Statistically significant decreases in recovery room time, postoperative narcotics, postoperative nausea and vomiting, and pain were achieved using rib blocks. All other measures were similar for both groups. There were no hospitalizations, pneumothoraxes, major complications or deaths. CONCLUSION: Rib blocks placed before the start of surgery result in decreased recovery room times, pain, and postoperative nausea and vomiting, achieving increased patient comfort and feasibility of performing abdominoplasties in the outpatient setting.