Compression Dressings Research Articles

Early ambulation after-grafting of lower extremity burns

ObjectiveEarly ambulation of lower extremity burns that undergo a skin graft may help to avoid some of the complications associated with immobilization. Despite recent evidence supporting early ambulation, post-operative immobilization following lower extremity skin grafting is still a common practice. The purpose of this study was to retrospectively assess the outcomes of lower extremity skin graft cases dressed with a multi-layer compression bandage who were ambulated in the immediate post-operative period. MethodsThis single centre observational study examined patients with a lower extremity burn that received a compressive dressing (Profore™) application immediately after surgical grafting and were ambulated no later than 1day post-operatively. ResultsForty-two burn patients (47 limbs) met inclusion criteria for this study. Of these 42 patients, 25 were operated on as an inpatient. The remaining 17 patients were done on an outpatient basis and discharged the same day of surgery. Mean patient age was 48.2 years and 34 (81.0%) of patients were male. Mean TBSA affected was 5.3% (792cm2). Mean number of procedures was 1 and mean graft take was 98.9%. Nearly all patients were ambulated within 1day of surgery. The graft take rate across all cases was 98.9±2.3%. No patients failed early ambulation with their compressive dressings, were readmitted or underwent repeated skin grafting. ConclusionsThis study demonstrates the excellent graft take rates that can be achieved with immediate ambulation following lower extremity skin grafting and challenges the conventional teaching of post-operative bed rest following lower extremity skin grafting procedures.

Anterior Incision Offloading for Primary and Revision Total Ankle Replacement: A Comparative Analysis of Two Techniques.

Background:There exists a high risk of post-operative complications with primary and revision total ankle replacement surgery. Delayed wound healing of the anterior incision is common. The reason for this is multi-factorial and, to date, most of the research has focused on predisposing factors involving the patients themselves. Only recently have researchers begun to look at the post-operative dressing as a possible consideration when trying to prevent incision wound healing complications. Currently, no standard post-operative dressing for primary or revision total ankle replacement exists. However, the principles of post-operative edema reduction to improve healing, as advocated by Sir Robert Jones and demonstrated in his compressive dressing, have been known for decades. We have been using a modified Sir Robert Jones compressive dressing for both primary and revision total ankle replacements. Recently, we have added an aperture pad made of cotton cast padding over the anterior incision in order to protect the area from pressure necrosis. Methods:This is a comparison study of the post-operative wound complications involving 35 patients that received the original dressing and 33 patients that received the addition of the aperture pad. Results:With no significant difference in the patient populations, the results demonstrate a 3-fold decrease in the number of anterior incision wound healing complications with the use of the aperture pad.Conclusion:This dressing represents a simple, reproducible, easy to apply and inexpensive way to prevent post-operative edema and anterior incision wound healing complications.

Serviço de atendimento móvel de urgência: epidemiologia do trauma no atendimento pré-hospitalar

Objetivo: caracterizar as vítimas de trauma atendidas pelo Serviço de Atendimento Móvel de Urgência (SAMU 192) no município de Ilhéus, na Bahia. Método: trata-se de um estudo descritivo e retrospectivo, no qual foram analisados 1.588 registros de eventos traumáticos a partir das seguintes variáveis: sexo, idade, dia da semana, período do dia, mecanismo de trauma, topografia e tipo das lesões, escore de trauma revisado, tipo de unidade móvel empregada, profissional responsável pelo atendimento, tempo até atendimento hospitalar, procedimentos realizados e óbitos. Resultados: houve predomínio de vítimas do gênero masculino (69,5%) e de idades entre 18 e 37 anos (46,5%). As ocorrências concentraram-se nos finais de semanas (37,8%) e no período noturno (52,0%). Evidenciou-se preponderância dos acidentes de trânsito (41,3%) como principal mecanismo do trauma, dentre os quais prevaleceram o envolvimento de motocicletas (73,0%). Em relação à distribuição topográfica da lesão, a maioria acometeu os membros (58,2%). As condutas mais adotadas no atendimento pré-hospitalar foram a imobilização (26,3%) e o curativo compressivo (25,9%). Os óbitos perfizeram 2,7% da amostra total. Conclusão: a população mais acometida por eventos traumáticos em Ilhéus demonstrou ser composta por jovens do sexo masculino envolvidos em acidentes de trânsito, principalmente motociclísticos, durante os fins de semana.

Skin Grafts Associated with Platelet Rich Plasma and Surgical Sponge - Literature Review

Skin graft is one of the techniques used to reconstruct surgical wounds. The graft is composed of epidermal and dermal segments that are completely removed from the donor region and transferred to the recipient bed. After its implantation it’s recommended to make compressive dressing in the receiver bed. Since the grafts do not have a vascular pedicle, it’s important to make the compressive dressing to improve graft contact with the wound and allow adequate angiogenesis. The compressive dressing is made with a sponge or foam, which offers adequate protection and reduces the discomfort of the patient in the postoperative period. The use of platelet-rich plasma (PRP) is the objective of several studies associated with the reduction of postoperative surgical complications, especially necrosis. This product is a result of the centrifugation of the patient’s blood that promotes the separation of its constituents and allows the extraction of plasma with higher concentration of platelets. PRP improves the tissue healing process by releasing biological mediators and growth factors at the site of application. Researches on platelet-rich plasma used in reconstructive surgery are important because this product has therapeutic characteristics to promote healing. When it’s used in skin grafts, platelet-rich plasma is able to improve graft integration in the recipient bed, and reduce necrosis after the surgical procedure. The use of postoperative surgical sponges associated with platelet-rich plasma is indicated to improve the healing of the graft and to avoid its displacement of the recipient bed.

A refined surgical treatment modality for bromhidrosis: Subcutaneous scissor with micropore.

Axillary bromhidrosis has a strong negative effect on one's social life. A high success rate and few complications are criteria for a surgical treatment. The objective of this study was to evaluate a new surgical treatment modality for bromhidrosis: subcutaneous scissor with micropore. Twenty patients with bromhidrosis were treated. Patients were placed in a supine position with their treated arms abducted to 110°. After injection of 60 mL of tumescent solution into each axilla, one small incision was made at the middle axillary of the hair-bearing area. The whole hair-bearing skin was undermined at the level of the superficial fat to obtain adequate skin eversion. The flaps were everted to offer full exposure of the apocrine glands, and meticulous excision of each gland was performed. Both sides were punctured with scalpel. The micropore was used for drainage, and whose width was just 3 mm. Finally, the incisions were re-approximated, and bulky compressive dressings were applied to the area for 72 hours. Of the 40 axillae (20 patients), 34 (85.0%) showed excellent results, and six (15.0%) had good results. Malodor was significantly decreased. There were no serious complications. This technique can produce excellent results with a lower complication rate than most other surgical modalities and can be performed without costly equipment.

Management of lymphatic fistulas in the groin from a surgeon's perspective

The postoperative occurrence of lymph fistulas in the groin is acomplication that should be taken seriously. These fistulas cause an increase in morbidity and can support local and ascending infections. The treatment of this complication ranges from conservative procedures, such as compression dressings and bed rest to operative treatment with detection of the fistulas and ligation, negative pressure wound therapy (NPWT) or even muscle flaps. This review provides an overview of current therapeutic modalities. On the basis of a current literature search via PubMed, we identified possible treatment options, which are described in this article. The conservative treatment options presented still have an importance in treating groin fistulas. Aselection of safe and effective interventional and operative treatments is presented. If there are indications for an interventional or operative treatment avariety of safe and effective therapies are available, which can significantly reduce the length of hospital stay. The option of treatment using amuscle flap is of value as alast resort in the treatment of infected vascular prosthesis in the groin of Szilagyi type III and should be used when necessary.

Comparing the Effects of Two Tourniquet Times on Pain and Knee Range of Motion after Internal Plate Fixation of Tibia Fractures

Background: Tourniquet is used in limb surgeries in order to create a clear blood-free surgical filed. Despite its considerable benefits, tourniquet has potential risks such as neuromuscular injuries, decreased joint range of motion, and pain. Present study was made to compare the effects of two tourniquet times on pain and knee range of motion after internal plate fixation of tibia fractures. Methods: This randomized controlled trial was performed on forty patients with acute closed extra-articular tibia fractures who were candidates for internal plate fixation. The patients were conveniently recruited and randomly allocated to groups A and B. In group A, tourniquet was deflated after tibial fixation and before wound closure while in group B, it was deflated after wound closure and compression dressing. The level of pain as well as knee range of motion were measured before, 24 hours after, and fourteen days after the surgery using a 30 cm goniometer and a 0-10 visual analogue scale, respectively. Results: Pain intensity score in group A was significantly lower than group B both at 24 hours and fourteen days after the surgery. Knee range of motion in group A was also significantly greater than group B at 24 hours after the surgery. However, fourteen days after the surgery, there was no significant difference between the groups regarding knee range of motion. Conclusion: Tourniquet deflation before wound closure is associated with lower levels of postoperative pain and greater postoperative knee range of motion among patients undergoing internal plate fixation of tibia fractures. Possible explanations for these findings are faster reperfusion, reduced duration of ischemia, and slighter ischemic and mechanical injuries to nerves, muscles, and the skin.

Treatment of chronic ulcers

SummaryChronic ulcers (CUs) are a major cause of morbidity and mortality with increasing prevalence, in part due to the ageing population, and an increase of risk factors such as diabetes and obesity. CUs are caused by numerous diseases including venous dysfunction, diabetes mellitus, infections, peripheral neuropathy, pressure, and atherosclerosis. The current standard therapy for CUs includes compression, surgical débridement, infection control, and adequate wound dressings. As a high percentage of CUs do not adequately heal or quickly relapse with standard treatments, additional therapeutic approaches are pursued, termed “advanced wound care therapies”. Here, an overview on commonly applied therapies lacking significant evidence for wound healing is reviewed, followed by therapies with significant evidence supporting the routine use in the treatment of CUs, and a short outlook in a possible future wound treatment landscape.To give a résumé, the presented literature reveals that most of the commonly applied topical and advanced ulcer treatments largely lack solid scientific evidence for the induction or acceleration of wound healing. Surprisingly only “classical” treatments such as wound cleansing, débridement and compression have significant evidence. Novel approaches such as bilayered skin reconstructs, cell suspensions or extracorporal shock waves seem promising. Considering the increasing number of ulcer patients, there is a strong need for further basic research to fully understand all factors involved in wound development and healing of the various ulcer pathophysiologies, and the urgent need for prospective clinical trials comparing the various treatment options.

The use of cling film to facilitate shower after total knee replacement surgery

Background: Total knee replacement (TKR) surgeries are arguably the most successful procedure in recent times. However, personal hygiene remains a big issue, especially in the immediate post operative period. The patients are not allowed to take shower for almost three weeks, due to the fear of wound wetting and eventual surgical site infection. We wished to report that in our institution, for all post operative patients, we use sterile occlusive dressings followed by the use of cling films and allow patients to take shower. Materials and methods: We studied 100 consecutive patients who underwent TKR surgeries at our hospital. All patients, after wound closure, received sterile occlusive dressings. Further, on post-operative day two, on removing the compression dressings, all operated knee joints were wrapped with cling film in order to allow patients to take proper shower. In this study group, we looked for the following outcomes; surgical site infections (SSI), number of change in dressing required before the completion of wound healing at 3 weeks post surgery. The overall patient satisfaction assessed by visual analogue scale (VAS;10 being happiest and 1 being most unhappy) at the end of two weeks. Results: In our study, there were no incidences of SSI, no change in dressing requirement till two weeks post surgery. The mean VAS score at end of two weeks were 8 out 10 indicating that most of our patients were happy with this arrangement. Conclusion: Use of cling film for allowing shower in patients undergoing total joint arthroplasty is a good option to maintain overall personal hygiene and high patient satisfaction rate.

Treatment of severe throracolumar fractures with posterior decompression, subtotal vertebrectomy, intervertebral fusion and internal fixation through unilateral pedicle

Objective To evaluate the effects of posterior decompression, subtotal vertebrectomy, intervertebral fusion and internal fixation through unilateral pedicle in the treatment of severe throracolumar fractures. Methods A retrospective study was conducted to evaluate the outcomes of 11 patients with severe throracolumar fracture who had been treated with posterior decompression, subtotal vertebrectomy, in-tervertebral fusion and internal fixation through unilateral pedicle at our department from March 2009 to March 2012. They were 10 males and one female, aged from 20 to 42 years (mean, 31.1 years). According to AO classification, there were 2 cases of type B1, 3 cases of type B2 and 6 cases of type C2. The Gaines scores for anterior column stability were more than 6 in all. All the patients had neurological disorders. The fracture reduction, fusion of bone grafting and recovery of neurological function were followed up. Results Their operation time ranged from 200 to 300 minutes, averaging 243.2 minutes; the amount of bleeding ranged from 800 to 1,600 mL, averaging 1,023.3 mL. No deterioration of neurological symptoms or no new neurological symptoms were observed postoperatively. Cerebrospinal fluid leakage was found in 3 patients who healed spontaneously following extubation, compressive dressing and elevation of the bed end. All the patients were followed up for 12 to 30 months (average, 18.3 months). A loosened screw cap was found in one patient after 6 months who had no discomfort and received no treatment. X-ray films showed satisfactory fracture reduction and fine bone grafting locations. No spinal canal stenosis was found by CT scans. It took 3 to 6 months (mean, 4.3 months) for the bone grafts to get fused. No height loss of the injured vertebrae was no found at the last follow-ups. No functional recovery was found in the patients with complete spinal cord injury whose Frankle grade remained A. The spinal function recovered from Frankel grade B to grade D in one patient with in-complete spinal injury. Of the 8 patients with medullary cone injury, 7 recovered Frankle grade E and one Frankle grade D. The symptoms were relieved in one patient with simple cauda equine injury. Conclusion Posterior decompression, subtotal vertebrectomy, intervertebral fusion and internal fixation through unilateral pedicle is an effective alternative for treatment of severe throracolumar fractures, because it can lead to satis-factory fracture reduction, thorough decompression of the spinal canal and good reconstruction of spinal sta-bility. Key words: Thoracic vertebrae; Lumber vertebrae; Fracture fixation, internal; Posterior; Subtotal vertebrectomy

Complications in Tibial Pilon Fractures: Avoiding Errors in Judgment

Pilon fracture surgery is fraught with many potential complications. Careful preoperative evaluation is required. Techniques for preoperative soft tissue management include compression dressings, stable ankle spanning external fixation, and compression foot pumps. Errors in judgment regarding the timing of surgery and over aggressive surgical exposure can lead to soft tissue complications. Postoperative wound management techniques include negative-pressure wound therapy to reduce incisional edema. Wound complications can be handled with a number of newer local pedicled rotational flaps, as well as biomaterials. These include acellular biomembranes to facilitate formation of a well-developed subcuticular tissue layer to serve as a substrate for local skin grafting. Mechanical instability occurs when the surgeon fails to neutralize deforming forces. This is accomplished by correct plate application, as well as treating areas of bone loss, that can all lead to late deformation, mechanical failure, and nonunion. This review covers crucial decision-making points regarding soft tissue and fixation strategies in an attempt to help avoid the frequency and severity of these complications. Levels of Evidence: Diagnostic Level I, II, III, IV, and V. See Instructions for Authors for a complete description of levels of evidence.

Estudio comparativo aleatorizado de la utilidad de órtesis de compresión controlada frente al apósito compresivo en el postoperatorio inmediato de la cirugía conservadora del cáncer de mama

ObjectivesTo compare the overall and individual incidence of postoperative complications, comfort and quality of life resulting from the use of compressive bandaging versus a specific controlled compression garment. Patients and methodA randomised controlled trial was conducted in 198 patients distributed in 2 groups: bandaging (n=88) and compression garment (n=99). Variables related to immediate postoperative complications and satisfaction with quality of life were collected. Changes in the variables were compared in the 2 groups during the first postoperative month. ResultsThe incidence of total complications was significantly lower with the compression garment: 7 days (P=.032) and 15 days (P=.009). Pain was significantly reduced with the compression garment: 7 days (P=.002) and 15 days (P=.012). The incidence of skin injury was also significantly reduced: 0-2% with the compression garment versus 35% with bandaging (P<0.0005). Significant differences were found in quality of life in favour of the use of the compression garment (P<0.0005). ConclusionsThe use of a specific controlled compression garment in the immediate postoperative period after breast cancer-conserving surgery reduces the likelihood of postoperative complications from 32 to 15% and enhanced efficacy, safety, and patient comfort compared with the usual compressive dressing.

The Impact of Tourniquet Release Time on Wound Healing in Patients Undergoing Tibia Fracture Plating Surgery

Background: The use of tourniquet is very common in orthopedic surgeries. By obstructing blood flow in the limb, tourniquet may result in muscle ischemia and skin flap hypoxia. This study aimed at determining and comparing the effects of tourniquet release time on wound healing in patients undergoing tibia fracture plating surgery. Methods: This study was a randomized clinical trial, wherein 40 patients with acute extra-articular tibia fractures were randomly assigned to 2 groups of A (releasing the tourniquet after fracture fixation and before wound closure) and B (releasing the tourniquet after wound closure and application of compression dressing). Duration of surgery in each group was recorded and independent t test was utilized to compare the 2 groups. The wound healing rate was investigated in the patients 24 hours and 14 days after surgery using the Redness, Oedema, Ecchymosis, Discharge, Approximation (REEDA) scale. In this tool, 0 represents “lack of the variable” and 3 indicates “maximum variable score”. The scores in this scale range from 0 to 15. The Mann-Whitney test was used in order to compare the wound healing rates between the 2 groups. Results: There was no significant difference between the 2 groups concerning the average duration of surgery. Wound redness, edema, ecchymosis, discharge, approximation, and the general condition of wound healing showed no significant difference in the 2 groups 24 hours after surgery, while there was a significant difference 14 days after surgery with the aforementioned parameters being greater in group B than group A. Conclusions: The results showed that releasing the tourniquet before wound closure in group A led to improved wound healing. Wounds need oxygen for restoration and prevention from infections. As the use of tourniquet occludes blood flow to the limb for a while, it can result in increased wound hypoxia after surgery and delayed healing process; hence, less tourniquet time is more desirable for oxygenation of tissues and wound dryness.

Compression Dressing Using Dental Impression Compound for Conservative Management of Sialocele.

A Sialocele or salivary pseudocyst is due to extravasation of saliva into periglandular tissue due to disruption of gland parenchyma. Various techniques of management have been described in literature; both conservative and surgical management have been documented. We report a simple economical and efficient method to deal with sailocele presenting after neck dissection.

Results of SMSNA Survey Regarding Complications Following Intralesional Injection Therapy With Collagenase Clostridium Histolyticum for Peyronie's Disease.

Intralesional injection of collagenase clostridium histolyticum (CCH) for Peyronie's disease (PD) can result in serious adverse events such as hematoma formation and corporal rupture. To investigate the prevalence of complications from CCH and management trends among CCH prescribers. A survey was sent to all 693 members of the Sexual Medicine Society of North America (SMSNA) with valid email addresses. Responders were asked to participate if they were prescribers of CCH. Data regarding prescriber experience with CCH, procedural preferences, and rates and management strategies of complications were collected. One hundred SMSNA members completed the survey, with 36%, 23%, and 41% of responders having performed ≤10, 10 to 20, and >20 CCH injections, respectively. Of the responders, 94% reported hematomas in <25% of patients, with 63% preferring to observe and 37% treated with a combination of observation, application of a compressive dressing, and/or drainage of the hematoma. Corporal ruptures were encountered by 34% of physicians at a median of 5 days (0.5 to 30 days) from the last CCH injection. Rupture was located over the treated plaque in 84% of cases, and surgical intervention was the preferred management option by 67% of members. A distal circumcising degloving incision was used in 76% of cases, and 62% of responders reported the quality of tissue to be worse than would be expected with a non-CCH penile fracture. There were no significant differences in erectile function, ability to have intercourse, change in penile curvature, and patient satisfaction among patients who underwent surveillance vs surgery. One observed patient developed a penile abscess. A wide variation exists among SMSNA members' strategies to prevent and manage complications of CCH. One in 3 prescribers reported encountering a corporal rupture during CCH therapy, and it is currently undetermined if there is a benefit of surgery vs conservative management.

Visible Perforating Lateral Osteotomy: Internal Perforating Technique with Wide Periosteal Dissection

There are two general categories of lateral osteotomy techniques—the external perforating method and the internal continuous method. Regardless of which technique is used, procedural effectiveness is hampered by limited visualization in the surgical field. Considering this point, we devised a new technique that involves using a wide subperiosteal dissection and internal perforation under direct visualization. Using an intranasal approach, whereby the visibility of the intended fracture line was maintained, enabled a greater degree of control, and in turn, results that were more precise, and thus predictable and reproducible. Traditionally, it has been taken as dogma that the periosteum must be preserved, considering the potential for dead space and bony instability; however, under sufficient visualization of the surgical field with an internal perforating method, complete osteotomy with fully preserved intranasal mucosa could be conducted exactly as intended. This intact mucosal lining compensates for the elevated periosteum. Compressive dressing and drainage through a Silastic angio-needle catheter enabled the elimination of dead space. Therefore, precise, reproducible, and predictable osteotomy minimizing the potential for associated complications such as ecchymosis, that is, bruising owing to hemorrhage, could be performed. In this article, we introduce a novel technique for lateral osteotomy with improved visualization.

Minimally-Invasive Repair of Bilateral Calcaneal Fractures with Unilateral External Fixation: A Case Report

INTRODUCTION AND OBJECTIVES: Calcaneal fractures are a serious injury with significant associated morbidity. Bilateral calcaneal fractures complicate issues even further, due to the physical disability that the patient is left with. One of the major issues with any calcaneal fracture is the risk of soft tissue compromise caused by the traumatic nature of the injury. A percutaneous approach allows the soft tissue envelope to remain viable, while still fixating the fractures. The purpose of this presentation is to highlight the use of percutaneous repair, the role of external fixation in calcaneal fractures, and lastly discuss the outcome for this particular patient. METHODS: A 26 year-old male presented to the office with bilateral calcaneal fractures, approximately 1 week after sustaining a fall from a height of 12 feet. The patient was brought to the operating room after spending approximately 2 weeks in bilateral posterior splints with Jones compressive dressings. The right calcaneal fracture was fixated percutaneously with 4 screws. The left calcaneal fracture was fixated percutaneously with 3 screws, as well as an Ilizarov external fixator. Approximately 8 weeks later, the patient returned to the operating room for removal of the external fixator and a cast application to the left lower extremity. RESULTS: The patient continued to progress and was subsequently transitioned into bilateral CAM walkers. In the following weeks, the patient was again upgraded to full weight-bearing with physical therapy. The fracture sites were completely consolidated with minimal to no pain in his bilateral heels and full ambulation. CONCLUSIONS: Percutaneous repair, along with external fixation, offers a viable alternative to ORIF for calcaneal fractures. A percutaneous approach also does not disrupt the potentially fragile soft tissue envelope in a calcaneal fracture. Although this outcome is positive, larger controlled studies are needed to confirm percutaneous approaches and external fixation in the realm of a calcaneal fracture.

Micro-fractional, directional skin tightening: A porcine model.

Skin changes are among the most visible signs of aging. Fractional ablative lasers improve skin quality by making small skin wounds that heal rapidly without scarring. While they improve skin texture and discoloration, there is minimal effect on skin laxity. This study was performed to assess skin shrinkage performed by removing multiple small full-thickness skin columns with coring needles combined with wound closure. In 5 swine 116 squares (3 cm(2) ) were demarcated for treatment and control sites. In treatment sites 10% of the skin was removed by full-thickness skin coring needles (19 gauge) and afterwards closed and compressed with an elastic adhesive dressing. This procedure was compared to puncturing the skin with standard hypodermic needles (without tissue removal) and subsequent closure with compressive dressing. Area and shape of sites were measured before and 28 days after treatment. Test and control sites healed within a week without scarring. Coring with wound closure caused significant shrinkage after 28 days. The treated skin area was reduced by 9% (P < 0.0001) and the direction of shrinkage was influenced by the direction of wound closure. Coring without wound closure and puncturing the skin without tissue removal produced an insignificant 3% decrease in area. Significant minimally invasive skin tightening in a preferred direction can be achieved by removing skin with coring needles followed by wound closure. The direction of shrinkage is influenced by the direction of micro-hole closure, irrespective of the skin tension lines. This approach may allow reshaping the skin in a desired direction without scarring.

Evidence-based Comprehensive Approach to Forearm Arterial Laceration

IntroductionPenetrating injury to the forearm may cause an isolated radial or ulnar artery injury, or a complex injury involving other structures including veins, tendons and nerves. The management of forearm laceration with arterial injury involves both operative and nonoperative strategies. An evolution in management has emerged especially at urban trauma centers, where the multidisciplinary resource of trauma and hand subspecialties may invoke controversy pertaining to the optimal management of such injuries. The objective of this review was to provide an evidence-based, systematic, operative and nonoperative approach to the management of isolated and complex forearm lacerations. A comprehensive search of MedLine, Cochrane Library, Embase and the National Guideline Clearinghouse did not yield evidence-based management guidelines for forearm arterial laceration injury. No professional or societal consensus guidelines or best practice guidelines exist to our knowledge.DiscussionThe optimal methods for achieving hemostasis are by a combination approach utilizing direct digital pressure, temporary tourniquet pressure, compressive dressings followed by wound closure. While surgical hemostasis may provide an expedited route for control of hemorrhage, this aggressive approach is often not needed (with a few exceptions) to achieve hemostasis for most forearm lacerations. Conservative methods mentioned above will attain the same result. Further, routine emergent or urgent operative exploration of forearm laceration injuries are not warranted and not cost-beneficial. It has been widely accepted with ample evidence in the literature that neither injury to forearm artery, nerve or tendon requires immediate surgical repair. Attention should be directed instead to control of bleeding, and perform a complete physical examination of the hand to document the presence or absence of other associated injuries. Critical ischemia will require expeditious surgical restoration of arterial perfusion. In a well-perfused hand, however, the presence of one intact artery is adequate to sustain viability without long-term functional disability, provided the palmar arch circulation is intact. Early consultation with a hand specialist should be pursued, and follow-up arrangement made for delayed primary repair in cases of complex injury.ConclusionManagement in accordance with well-established clinical principles will maximize treatment efficacy and functional outcome while minimizing the cost of medical care.

Endoscopic submandibular gland resection preserving great auricular nerve and periaural sensation.

The preservation of periaural sensation is one of the most important things to improve the postoperative quality of life after performing the surgical procedures via retroauricular approach. The aim of this study is to describe the surgical technique of endoscopic submandibular gland (SMG) resection through the potential plane between great auricular nerve (GAN) and sternocleidomastoid muscle (sub-GAN dissection) and to evaluate its technical feasibility and advantage. The present study enrolled 22 patients who underwent endoscopic SMG resection through linear hairline incision and sub-GAN dissection. The assessment was performed on the following: the cosmetic satisfaction after surgery and surgery-related variables. There was one case of a postoperative hematoma, which resolved with conservative management via a compression dressing, and one case of transient numbness at the surgical site, which spontaneously resolved within two months. In all other patients, no complications, such as seroma, skin necrosis, or marginal mandibular nerve palsy, occurred. The mean scores of pain and paresthesia evaluated with the graded scale approximated 0 (no pain or paresthesia). The cosmetic result score was as low as 1.5 ("extremely satisfied" or "satisfied"). Linear hairline incision and sub-GAN dissection were feasible to acquire the sufficient working space for endoscopic SMG resection without sensory deterioration of GAN. This procedure may be useful to apply the surgery of other upper neck masses or thyroidectomy via retroauricular approach.