Power-assisted Liposuction and a Single Incision Pull-through Technique for Top Surgery: A Case Report.

Various treatment approaches exist for female-to-male subcutaneous mastectomy, also known as "top surgery." The most commonly performed techniques for patients with decreased volume of breast tissue, no ptosis, and good skin elasticity continue to involve areolar or periareolar incision. Here, we report a case of a 17-year-old patient who underwent top surgery performed through power-assisted liposuction and a non-areolar single-incision "pull-through" technique. Operative management included initial liposuction for contouring of adipose tissue. Surgical subcision of excess breast tissue adherent to the subdermal plane was then performed and removed with a grasp-and-pull motion using the pull-through technique. We obtained a favorable result with low scar burden, preserved nipple sensation, and no nipple contracture. No complications were reported. This procedure is limited for patients with small breast size (A cup, <100 grams of glandular tissue per side), minimal to no ptosis, appropriate nipple size and position, soft fibroglandular tissue, and good skin elasticity.

Cases of Early Infectious Flexor Tenosynovitis Treated Non-Surgically With Antibiotics, Immobilization, and Elevation.

BACKGROUND: Early infectious flexor tenosynovitis has been treated with urgent surgery by most surgeons since Bunnell wrote the first textbook of hand surgery in 1945. Some surgeons have good experience with non-surgical management of early presenting disease in some cases. METHODS: This retrospective chart review included 12 inpatients with early infectious flexor synovitis who received conservative treatment with antibiotics, immobilization, and elevation without surgical drainage. RESULTS: The mean time to resolution of infective symptoms for the 12 patients was 5 days (range: 2-11 days) for those receiving conservative management. Half of them required hand therapy. Eight of the 12 patients had good documentation of a full return of hand function. CONCLUSIONS: In some patients with early infectious flexor synovitis, urgent surgery may not be required. We present a brief synopsis of 12 such cases.

HISTORIQUE: La plupart des chirurgiens opèrent d'urgence les ténosynovites infectieuses précoces des fléchisseurs depuis que Bunnell a rédigé le premier manuel sur les chirurgies de la main en 1945. Certains chirurgiens possèdent une bonne expérience de la prise en charge non chirurgicale de certains cas à présentation précoce. MÉTHODOLOGIE: La présente analyse rétrospective des dossiers médicaux portait sur 12 patients hospitalisés à cause d'une synovite infectieuse précoce des fléchisseurs qui avaient reçu un traitement prudent au moyen d'antibiotiques, d'une immobilisation et d'une élévation, sans drainage chirurgical. RÉSULTATS: La période moyenne jusqu'à la résolution des symptômes des 12 patients ainsi traités était de cinq jours (plage de deux à 11 jours). La moitié d'entre eux ont dû subir une chirurgie de la main. Huit des 12 patients présentaient une reprise complète de la fonction de la main bien étayée. CONCLUSIONS: Chez certains patients atteints d'une synovite infectieuse précoce des fléchisseurs, la chirurgie d'urgence n'est pas nécessaire. Les auteurs présentent un synopsis de ces 12 cas.

Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet.

BACKGROUND: In our experience, for all surgeries in the hand, the optimal epinephrine effect from local anesthesia-producing maximal vasoconstriction and visualization-is achieved by waiting significantly longer than the traditionally quoted 7 min from the time of injection. METHODS: In this prospective comparative study, healthy patients undergoing unilateral carpal tunnel surgery waited either 7 min or roughly 30 min, between the time of injection of 1 % lidocaine with 1:100,000 epinephrine and the time of incision. A standardized incision was made through dermis and into the subcutaneous tissue followed by exactly 60 s of measuring the quantity of blood loss using sterile micropipettes. RESULTS: There was a statistically significant reduction in the mean quantity of bleeding in the group that waited roughly 30 min after injection and before incision compared to the group that waited only 7 min (95 % confidence intervals of 0.06 + -0.03 ml/cm of incision, compared to 0.17 + -0.08 ml/cm, respectively) (P = 0.03). CONCLUSIONS: Waiting roughly 30 min after injection of local anesthesia with epinephrine as oppose to the traditionally taught 7 min, achieves an optimal epinephrine effect and vasoconstriction. In the hand, this will result in roughly a threefold reduction in bleeding-making wide awake local anesthesia without tourniquet (WALANT) possible. This knowledge has allowed our team to expand the hand procedures that we can offer using WALANT. The benefits of WALANT hand surgery include reduced cost and waste, improved patient safety, and the ability to perform active intraoperative movement examinations.

Inexpensive diffuse reflectance spectroscopy system for measuring changes in tissue optical properties.

The measurement of changes in blood volume in tissue is important for monitoring the effects of a wide range of therapeutic interventions, from radiation therapy to skin-flap transplants. Many systems available for purchase are either expensive or difficult to use, limiting their utility in the clinical setting. A low-cost system, capable of measuring changes in tissue blood volume via diffuse reflectance spectroscopy is presented. The system consists of an integrating sphere coupled via optical fibers to a broadband light source and a spectrometer. Validation data are presented to illustrate the accuracy and reproducibility of the system. The validity and utility of this in vivo system were demonstrated in a skin blanching/reddening experiment using epinephrine and lidocaine, and in a study measuring the severity of radiation-induced erythema during radiation therapy.

Optimal time delay between epinephrine injection and incision to minimize bleeding.

BACKGROUND: The time until maximal cutaneous vasoconstriction after injection of lidocaine with epinephrine is often given in textbooks and multiple choice examinations as 7 to 10 minutes. However, in our experience, there is significantly less cutaneous bleeding if one waits considerably longer than 7 to 10 minutes after injection of local anesthesia with epinephrine for most procedures on human skin. METHODS: This was a prospective, randomized, triple-blind study where 12 volunteers were injected simultaneously in each arm with either 1% lidocaine with epinephrine (study group) or 1% plain lidocaine (control group), after which the relative hemoglobin concentration of the underlying skin and soft tissues was measured over time using spectroscopy. RESULTS: In the epinephrine group, the mean time at which the lowest cutaneous hemoglobin level was obtained was 25.9 minutes (95 percent CI, 25.9 ± 5.1 minutes). This was significantly longer than the historical literature values of 7 to 10 minutes for maximum vasoconstriction after injection. Mean hemoglobin index values at every time measurement after postinjection minute 1 were significantly different between the study group and the control group, with use of a two-tailed paired t test (p < 0.01). CONCLUSIONS: If optimal visualization is desired, the ideal time for the surgeon to begin the incision should be 25 minutes after injection of local anesthetic with epinephrine. It takes considerably longer than 7 to 10 minutes for a new local equilibrium to be obtained in relation to hemoglobin quantity.