Incision Line Research Articles

Predictibility and aesthetics in the anterior sector

Introduction: Today the aesthetic demand in dentistry occupies the first places in terms of consultation needs in the dental office, that is why, as providers of dental health services, we are obliged to offer treatment options that meet standards of quality, functionality, aesthetics, predictability among other things and that are available to different social levels4. There are techniques that supported by elements such as Digital Smile Design (DSD) 9, wax up and mockup5 offer excellent, predictable aesthetic results, with the option of choosing different materials that are available to all our patients from composite resin to better than we find today; the porcelain clinical case: A 25-year-old female patient who goes to a dental office for teeth whitening, when diagnosing the case, the presence of diastema was observed in the upper centers, as well as anomalies regarding aesthetic smile parameters such as pigmentation, proportions , incisal edge line, among other things. Diagnostic waxing, mockup and photographs were performed to evaluate the result. The treatment plan consisted of 6 resin veneers made with the fluid resin injection technique through a transparent silicone matrix (Flow injection technique). RESULTS: The prognosis of the case is considered favorable, taking into account that the treatment with Resins is not definitive, however functional and aesthetic results were achieved properly. Conclusions: There are several treatment alternatives for the solution of aesthetic problems, which adapt to the possibilities of each patient, the mockup is a necessary tool for obtaining predictable treatments. The fluid resin injection technique is a good aesthetic and functional treatment, which sometimes does not require the minimum wear of the teeth to be treated.

THE FEATURES OF THE FACE SKIN CONSTRUCTION THAT INFLUENCE ON THE FORMATION OF CICATRICAL TISSUES DURING SUGICAL INTERVENTIONS

Formation of pathological scars of maxillofacial localization after surgery is a significant and widespread problem of modern surgical stomatology and maxillofacial surgery. A significant percentage of patients who needs planned and urgent surgical interventions cause rapid development of reconstructive-restorative surgery of the maxillofacial region.
 The analysis of domestic and foreign literary sources was devoted to the peculiarities of the structure of the skin of the head and neck and the optimization of the skin incisions of this localization.
 Functional features of human skin depend on the mechanical properties of the dermis, which provides elasticity and resistance to stretching. Changes in the biomechanics of the dermis occur during aging, excessive insolation, scarring, and fibrosis. In addition, mechanical changes in the extracellular matrix of the skin affect the activity and phenotype of the fibroblasts, which adapt the stiffness of the cytoskeleton. Extracellular matrix stiffness defines and maintains cell identity and influences the proliferation, differentiation, migration and expression of skin cells.
 The extracellular matrix has been regarded for a long time as a structure with simple architectonics. But, due to modern research, it is known that this complex formation is highly specialized. The different classes of macromolecules that make up the extracellular matrix determine its biological functions. For example, collagen proteins are responsible for the tensile strength of tissues, proteoglycans and glycosaminoglycan are important for hydration and compression resistance, and glycoproteins such as laminas facilitate cell attachment. The largest structures of the extracellular matrix are elastin fibers, which are mainly localized in tissues subject to high mechanical stress, such as skin, lungs, or arteries. These structures represent a very complex organization whose core consists of elastin surrounded by a mantle of microfibrils.
 Collagen proteins in the dermis contain mainly type I collagen (85% - 90%) with smaller amounts of type III collagen (10% - 15%). Skin fibroblasts synthesize individual collagen type I and III polypeptide chains as precursor molecules, called procollagens. During the formation of insoluble collagen fibrils, specific proteases break down the carboxy- and amino-terminal domains, forming pN-collagen (procollagen from which the carboxy-terminal domain propeptide is cleaved) and pC-collagen (procollagen, from which the amino-terminal propeptide is cleaved). Because type I and III procollagen, pN-collagen and pC-collagen are precursors of mature collagen molecules, their level usually reflects the level of collagen biosynthesis.
 Collagens and elastin contain highly abundant fibrils, each of which is repeated in a sequence enriched in the conformation of polyproline II, cross-linked, insoluble in assembly and resistant to the most photolytic enzymes. The monomeric block of type I collagen consists of two extended chains α1 and one chain α2, twisted together into a triple helix.
 The direction of collagen and elastin fibers, according to biomechanical studies, has a significant effect on the enlargement of the wound on the head skin and the tension when closing its edges. The overwhelming reduction of tension and accordingly the improvement of reparative processes in the skin occur when the incision lines correspond to the so-called "golden spiral".
 Conclusion. Thus, the analysis of domestic and foreign literature sources indicates the relevance of the selected topics, the need for further studies on the biomechanical and histological substantiation of incisions, which are due to the peculiarities of the structure of the skin in the head and neck to create optimal conditions for reparative regeneration.

Optimal Suture Bite Size for Closure of Feline Linea Alba-A Cadaveric Study.

Objective: This study aimed to determine the most appropriate suture bite and stitch interval (SBSI) size for closing feline linea alba.Study design: Randomized ex vivo mechanical testing.Sample population: Ventral abdominal walls from 35 male feline cadavers were harvested and separated into 125 segments.Methods: Segments were incised along midline then sutured back together using 3-0 polydioxanone using one of the following SBSI: 3, 5, 7.5, or 10 mm whereby the distance represents the distance both between the suture bites, and from the bite to incision line. The location of segments as well as the weight of the cadaver were recorded. A single linear distraction mechanical breaking test was performed. Statistical analyses (logistic and linear regression) were performed to determine which factors were associated with visual and mechanical failure, as well as load at failure or maximum displacement.Results: SBSI was significantly associated with load at failure or maximum displacement (p < 0.001). In particular, 5 mm SBSI had the highest load at failure amongst all the bite sizes (LSmeans = 27.55N, 95% Confidence Interval (CI): 23.65–31.44); this was significantly higher than 7.5 mm (LSmeans = 19.15N, 95% CI: 15.26–23.05, p = 0.016) and 10 mm (LSmeans = 16.55N, 95%CI:12.39–20.70, p = 0.0012) but not significantly higher than 3 mm (LSmeans = 23.78N, 95% CI: 19.69–27.86, p = 0.2). Increased SBSI increased the odds of visual failure (p < 0.001) whereas increased weight of the cadaver reduced the odds of visual failure (OR = 0.52, 95%CI: 0.30–0.88, p = 0.016).Conclusion: The 5 mm SBSI had the highest load at failure and was not significantly different from the 3 mm SBSI when apposing feline linea alba using 3-0 polydioxanone.Clinical significance: Using 5 mm SBSI is the preferred bite size compared to 7.5 or 10 mm SBSI when apposing feline linea alba with 3-0 polydioxanone.

Comparison of the Effects of Ultrasound-guided Erector Spinae Plane Block and Wound Infiltration on Perioperative Opioid Consumption and Postoperative Pain in Thoracotomy.

To compare the effects of preoperative ultrasound-guided erector spinae plane block (ESPB) and preoperative wound infiltration on perioperative opioid consumption and postoperative pain in thoracotomy. Randomised controlled trial. Department of Anesthesiology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, from October 2018 to April 2019. Sixty adult patients undergoing open esophagectomy were allocated randomly into two groups: experimental group (ultrasound-guided ESPB group, n = 30) and control group (wound infiltration group, n = 30). In ultrasound-guided ESPB group (group EB), ESPB with 20 ml of 0.5% ropivacaine was performed at the level of thoracic 5 transverse process. Whereas, in wound infiltration group (group WI), 20 ml of 0.5% ropivacaine was injected subcutaneously along the marked line of skin incision for surgery and chest tube placement. The perioperative opioid consumption, pain scores at rest and during coughing immediately after surgery, at postoperative day (POD) 1 and POD 2, consumption of rescue analgesic tramadol and postoperative opioid-related adverse events were all assessed. Compared with group WI, the intraoperative and postoperative opioid consumptions, postoperative tramadol consumption were significantly less in group EB (p <0.05). Moreover, the postoperative pain scores immediately after surgery, at POD 1 and POD 2, were all lower in group EB compared to group WI (p <0.05). Significantly, the postoperative incidence of nausea and vomiting was lower in group EB than that in group WI (p = 0.021). Compared to wound infiltration with local anesthetics, preoperative ultrasound-guided ESPB could significantly reduce perioperative opioid consumption, provide a better postoperative analgesia and reduce opioid-related adverse events in thoracotomy.

A temporary bypass used in end-to-end anastomosis of major vessels without stopping blood flow in the segment under repair

The authors developed an original set of tools and a method of carrying out end-to-end anastomosis on major vessels, without stopping blood circulation in the vascular segment being repaired. The proposed set of tools includes 10 tubes (temporary vascular grafts) made of medical silicone with external diameters from 8 to 26 mm. The length of each tube is not less than 10 cm, and the wall thickness is 1.2 mm. A spiral notch with a step of 1.2 mm is made on the outer surface of the tubes, to a depth of 1 mm. The set of tools also includes a set of metal hollow half cylinders with a through hole made in the middle, designed to extract the temporary shunt of the appropriate diameter. Before the formation of a vascular anastomosis, a silicone tube is selected, the outer diameter of which corresponds to the inner diameter of the damaged vessel. It is necessary to cut off a length of the tube, so that 23 cm of it could be introduced into the lumen of the proximal and distal segments of the damaged vessel. A stay-suture is laid in the center of the temporary bypass, on a site of its wall between two neighboring spiral notches. The ends of the temporary bypass, pre-filled with saline solution, are introduced into the distal and proximal ends of the divided vessel and are firmly fixed in the lumen of the vessel with two elastic bands. After placing the temporary bypass in the lumen of the damaged vessel, the blood flow is restored. Using the intraluminar temporary shunt as a scaffold, the edges of the vessel are approximated and stitched to its entire circumference, tying the first and last stitches of this seam. The last additional suture is placed in the area of the stay-suture overlying the wall of the temporary vascular shunt and is not tightened. A half-cylinder is placed above the untightened vascular suture and a stay-suture is placed at its opening. After that, tightly pressing the metal hollow half-cylinder to the vascular wall, and applying traction to the ends of the stay-suture the mechanical destruction of the silicone tube along the line of the spiral incision ensues. As a result, the tube is transformed into a double silicone rod, which is pulled through a through hole in the metal half-cylinder floor. After the extraction of the tube, the anastomosis is completed by tying a knot on the provisional suture. To simulate the proposed method, 10 operations were performed using a closed experimental circuit that completely simulates the real situation of restoring a damaged major vessel. The time of the operation, the technical features of the intervention, as well as the volume of blood loss, which was estimated by reducing the volume of blood circulating in the experimental circuit, were evaluated. Experimental testing with the use of a model simulating the situation of restoring a damaged major vessel, demonstrated the effectiveness of the developed method of applying a vascular end-to-end anastomosis with the use of a destructible temporary bypass; the average time of the operation was 10 minutes, and the volume of blood loss did not exceed 5 ml. The proposed set of tools and method can be effectively used in case of major vessels injury. The technique completely excludes the need for interrupting blood flow through the sutured vessel; it allows to reduce the volume of blood loss in vascular trauma, minimizes the time of ischemia in the area of blood supply to the damaged artery or venous stagnation of the drained segment (when suturing a vein), as well as to facilitate the imposition of a vascular suture to surgeons who do not have sufficient qualification in vascular surgery.

Ex vivo comparison of the effect of storage temperature on canine intestinal leakage pressures.

To determine the effect of storage temperature on cadaveric small intestinal leakage pressures after enterotomy. Experimental ex vivo study. Grossly normal jejunal segments from four canine cadavers. Thirty-six jejunal segments (n = 12 segments/group) were harvested immediately after euthanasia and assigned to a fresh group (tested within 4 hours), chilled group (stored for 24 hours at 4°C before testing), or freeze-thaw group (frozen at -20°C for 7 days and thawed at 21°C for 6 hours before testing). A 2-cm antimesenteric enterotomy was performed and repaired with 4-0 monofilament suture in a simple-continuous pattern. Initial leakage pressure (ILP), maximal intraluminal pressure (MIP), and leakage location were recorded, with testing performed at room temperature. Mean ± SD ILP for fresh, chilled, and frozen-thawed specimens was 52.9 ± 8.4, 51.8 ± 11.9 and 29.8 ± 4.4 mm Hg, respectively. There was a difference in ILP among groups (P < .003), with freeze-thaw samples demonstrating lower ILP compared with other groups. There was no difference in MIP between groups (P = .186) There was a difference in leakage location among groups (P = .004), with the majority of chilled and freeze-thaw samples leaking at the suture holes compared with the incisional line in fresh samples. Freezing and subsequent thawing prior to specimen testing reduced ILP compared with use of fresh and chilled specimens but did not affect MIP among experimental groups. Cadaveric canine intestinal specimens tested immediately after collection or after chilling for 24 hours should be recommended for ex vivo burst pressure assessment in dogs. Additional studies to evaluate loss in testing viability of chilled intestinal specimens are warranted to help govern experimental methodologies.

The Pectoralis Major Island Flap: Short Scar Modified Muscle-Sparing Harvesting Technique Improves Aesthetic Outcome in Reconstructive Head and Neck Surgery

Background: Pectoralis major flap reconstruction is often associated with large unappealing scars in head-neck surgery. We recently established an alternative harvesting technique that improves aesthetic outcome. Objectives: The objective of this study was to demonstrate a modified surgical technique that harvests the pectoralis major muscle as an island flap and focuses on minimizing incision lines and applying a muscle-sparing approach. Methods: A retrospective analysis covering the period 2008–2018 was conducted. Patients who underwent pectoralis major island flap reconstruction for fistula prophylaxis after salvage laryngectomy at the Medical University of Innsbruck were included. Flap harvesting was performed subcutaneously using two small incision lines, thereby sparing the clavicular and upper sternocostal aspects of the pectoralis muscle. Results: Twenty-three patients with squamous cell carcinoma of the larynx (n = 19) or pharynx (n = 4) underwent salvage laryngectomy and consecutive reconstruction using a pectoralis major island flap and our muscle-sparing technique. Mean overall operation time was 147 ± 48.6 min. The majority (70%) of patients had an uneventful course of recovery and showed satisfying aesthetic results and low donor site morbidity as compared to traditional harvesting techniques. Six (26%) patients had major complications that required surgical revision. Three (13%) cases were complicated with fistulas. Conclusion: The pectoralis major island flap is shown to be reliable in otolaryngeal surgery. This surgical technique minimizes scarring and preserves thoracic wall architecture by taking a less invasive approach, thereby improving aesthetic outcome and reducing overall patient morbidity.

Excision of thyroglossal cyst in children by transverse submentum incision

Objective:To explore the application of transverse submentum incision in thyroglossal duct cyst surgery. Method:Submentum transverse incision for thyroglossal duct cyst removal in 14 children with thyroglossal duct cyst from January 2014 to December 2017. All cases were performed submentum dermatoglyphic incision, skin incision, subcutaneous tissue, platysma muscle incision, down lifting flap, along the white line incision and separation of banded muscle on both sides, see the mass along the wall of the capsule separated to the attachment of the hyoid bone, ablation of the mucosa of the capsule wall of the hyoid bone attachment, electrotome to break the hyoid bone. The cavity is indeed stopped after bleeding, and the skin is sutured continuously for continuous intradermal suture. The operation time, bleeding volume, severe complications, wound healing time and severe surgical scars were recorded. Close follow-up was performed to observe whether there was infection or recurrence of incisional wound. Parents were informed by telephone to go back to the outpatient clinic. RUTTER Children's Behavior Questionnaire was used to assess the children's psychological status. Vancouver Scar Rating Scale was used to evaluate the children's surgical scars, and to investigate whether parents satisfactory surgical methods. Result:Fourteen cases of thyroglossal duct cyst underwent transverse incision thyroglossal duct cyst excision successfully. The average operative time was 55 minutes, and the standard deviation was 10.5 min, bleeding was less than 10 ml, postoperative hoarseness and weakness of voice, silence became low, wound healing time averaged one week, no serious surgical scars, no wound infection and recurrence. Among the normal children of the same age group, 14 parents were satisfied with the operation. Conclusion:Excision of thyroglossal duct cyst under transverse incision is safe, reliable and satisfactory in appearance.

Lateral femoral cutaneous nerve block with different volumes of Ropivacaine: a randomized trial in healthy volunteers

BackgroundNerve block of the lateral femoral cutaneous nerve (LFCN) is a predominantly sensory block. It reduces pain following total hip arthroplasty (THA), but the non-responder rate is high. We hypothesized, that an increased volume of ropivacaine, would result in greater coverage of incisions used for THA.MethodsWe conducted a randomized, blinded trial in 20 healthy volunteers. Participants were randomized to receive bilateral LFCN-blocks with 8 mL ropivacaine 0.75% on the left side and 16 mL ropivacaine 0.75% on the right side, or vice versa. Allocation was blinded to both participants and outcome assessors. Before nerve block performance, incision lines for posterior and lateral THA approaches were depicted with invisible ultraviolet-paint, thereby securing sufficient blinding during outcome assessment. The blocked area was mapped using temperature and mechanical discrimination tests. Quadriceps muscle strength was monitored. Primary outcome was coverage of the posterior incision line assessed by temperature discrimination test.ResultsWe found no difference in coverage of the posterior or lateral incision lines when comparing LFCN-blocks with 8 mL versus 16 mL of ropivacaine. The blocked area was significantly larger in the 16 mL group, assessed by both temperature discrimination test (p = 0.012) and mechanical discrimination test (p = 0.034). We observed no difference between groups regarding quadriceps muscle strength (p = 1.0).ConclusionsA LFCN-block with increased volume of ropivacaine from 8 mL to 16 mL did not result in a greater coverage of posterior or lateral incision lines used for THA, but in a larger blocked sensory area.Trial registrationClinicaltrials.gov: NCT03138668. Registered 3rd of May 2017.

Triangular excision and submucosal rejoining to correct horizontally folded caudal nasal septum.

Surgical correction of severe caudal deviation of nasal septum using an endonasal approach is challenging for surgeons. Among cases of severe caudal septal deflection, fracture lines along the horizontal direction are occasionally encountered during the surgery. We devised a simple and efficient technique called "triangular excision and submucosal rejoining" to address this kind of deformity. A total of 9 patients with severe caudal septal deflection underwent "triangular excision and submucosal rejoining." After the removal of the deformed posteroinferior portion of the quadrangular cartilage, 2 incision lines were made on the remaining caudal septum, starting from a point at the most anterior portion of the fracture line and diverging posteriorly above and below the fracture line. After removing a triangular cartilaginous piece, the upper and lower remaining cartilage segments were approximated using a single or 2 simple interrupted sutures. Sutures exiting the mucosa were re-entered from the exit point so that all the sutures were buried underneath the mucosa while the mucosal flap was elevated only unilaterally. This technique was effective in all cases. Septal batten grafts were applied in 3 patients, in whom the remaining quadrangular cartilage was weak and thin. One patient showed a mildly recurred septal deviation, but the nasal cavities remained patent with no symptoms. Serious complications such as dorsal saddling or tip ptosis did not occur in any cases. "Triangular excision and submucosal rejoining" may be a safe and efficient septoplasty technique to correct a horizontally folded caudal septum.

Comparison of the Effects on the Postoperative Analgesia of Bupivacaine or Ropivacaine Application on Intraperitoneal and Incisional Line during Ovariohysterectomy in Dogs

Bu çalışmada köpeklerde genel anestezi altında gerçekleştirilen ovariohisterektomi sırasında intraperitoneal ya da ensiyon hattına lokal olarak uygulanan bupivacaine ve ropivacainin postoperatif analjezi üzerine etkisinin karşılaştırmalı olarak değerlendirilmesi amaçlandı. Ksilazin-ketamin genel anestezisi altında ovariohisterektomi yapılan köpekler, her birinde 8 hayvan olacak şekilde 2 gruba ayrıldı. İlk gruba (BG, n=8) operasyon sırasında korpus uteri ile serviks uteri arasına yapılan ensiyon hattına (I), intraperitoneal (II) olarak ve kas üzerindeki ensizyon hattı (III) olmak üzere farklı üç noktaya bupivacaine diğer grubta (RG, n=8) ise benzer şekilde bu üç noktaya ropivacaine uygulaması yapıldı ve operasyon rutin bir şekilde tamamlandı. Operasyondan sonraki 2., 4., 6., 8., 12. ve 24. saatlerde nabız, solunum sayısı ve vücut sıcaklığı ölçümleri yapıldı. Benzer şekilde aynı saatlerde her bir köpek basit ağrı tanımlama (SDS) skalası, Melbourne ağrı skalası ve Glaskow kompozit ağrı skalaları kullanılarak değerlendirildi. Özellikle nabız bakımından gruplar arasında istatistiksel farklar bulunsa da nabız, solunum sayısı ve vücut sıcaklığı değerleri referans sınırlar arasında idi. SDS ve Melbourne ağrı skalasının değerlendirme sonuçlarına göre postoperatif 4. ve 6. saatlerde BG ve RG arasında istatistiksel bir fark belirlendi (P&amp;lt;0.001, P=0.003). Glaskow kompozit ağrı skalasının sonuçları 4. saatte gruplar arasında istatistiksel olarak anlamlı bir fark bulundu (P&amp;lt;0.001). Sonuç olarak çalışmadan elde edilen veriler bir arada değerlendirildiğinde uzun etkili bir lokal anestezik olan bupivacainin köpeklerde ovariohisterektomi operasyonlarında ensizyonel ve intraperitoneal kullanımının postoperatif analjezik etkisinin ropivacaine göre daha güçlü olduğu sonucuna varıldı.

Study of Aesthetic Components of Smile in North Indian Males

Smile is an important physical factor for reflection of inner emotions and well being of person. People with an aesthetic smile are judged socially attractive. It would be useful to represent some desirable characteristics of the smile, which help to achieve desirable results in surgical and aesthetic oral rehabilitation. To analyze the various aesthetic components of smile, assessing the teeth displayed during smile, relationship between curve formed by incisal line of anterior maxillary teeth and the curve of lower lip, the touch of this incisal line on lower lip, the alignment of facial midline with the arch midline and compared the data with the previous studies. The study comprises of 200 North Indian males age group 18-40 years. Prior informed written consent for this study was obtained from the subjects. The exclusion and inclusion criteria for the subjects were predefined. Photographs were taken both in rest position as well as in Smile position using digital camera with high resolution. Results show that during smile the position of upper lip was average in 49% of males, alignment of upper incisal edge to lower lip was convex in 47%, tooth lower lip was non touching in 60%, no. of teeth displayed during smile was 8-10 in 68%, midline from philtrum passing through the centre of central incisors in 76% and bilateral negative space was not visible in 92% males. So, it is concluded that smile is aesthetic in North Indian males.

A Reevaluation of the Gritti-Stokes (Above-Knee) Amputation for the Nonambulatory Patient

To reevaluate the benefits of a Gritti-Stokes amputation (GSA), as an alternative to the traditional above-knee amputation (AKA), in patients who are nonambulatory or not a candidate for a below-knee amputation (BKA). A fish-mouth incision is fashioned below the tibial tuberosity into the popliteal crease, resulting in an anterior soft tissue flap and smaller posterior soft tissue flap. Thus the incision line will be on the posterior thigh, instead of the end of the stump. The patellar tendon is detached from the anterior tibial tuberosity, then the dissection is carried proximally behind the patellar tendon and the adjoining tendons of the vastus medialis and vastus lateralis, until the patella can be flipped over to expose the posterior patellar surface and joint capsule. The patellar's posterior surface is shaved down flat to medulla bone, with an electric small-toothed bone saw and large bur. The femur is then cleared circumferentially at its base. The foot is then placed at 90°, creating a 45-degree angle between the femur and the tibia, and the femur is then transected with a Gigli saw near the base or just above the base, depending on the size of the patellar surface area. This creates a 45-degree angle to the femur posteriorly, which allows the shaved patella to be secured to the end of the femur, with less chance of shifting. The fascia is then circumferentially closed around the patella and femur. Then, the remnant patellar tendon is sutured to the tendons of the posterior compartment. The dermis and skin are then closed in the standard tension-free manner using 2-0 interrupted vicryl sutures, followed by interrupted 2-0 nylon vertical mattress sutures. The dressing consisted of a single layer of ADAPTIC Non-Adhering Dressing to allow drainage, gauze fluffs, 6-inch kerlix, and finally a 6-inch ACE wrap was applied. The dressings are left intact for 2-3days and then replaced daily thereafter. A retrospective chart review was performed to identify patients who had undergone a GSA from January 2016 to September 2017 by a single surgeon. Estimated blood loss (EBL), operative time, and perioperative and postoperative complications were assessed. A total of 16 GSAs were performed on 15 patients by a single surgeon between January 7, 2016 and September 19, 2017. In our series, intraoperative outcomes were notable for an average EBL of 114mL, lower than the traditional AKA (average EBL: 300-500mL) with comparable operative times as short as 90min (skin incision to dressing). No transfusions were required in the GSA group (postop days: 1-4) compared with traditional AKA group which required an average of 2.1 units. Postoperative outcomes showed low complication rates. Postoperative complications were limited to 2 cases of a stump infection, which were treated with local wound care and subsequently healed completely. One patient died from septic shock secondary to pneumonia unrelated to the GSA surgery. A reevaluation of the GSA in the nonambulatory patient population is warranted in the United States as an alternative to the traditional AKA whenever possible. Our experience with a small series of GSA's has yielded promising advantages including potential for decreased blood loss and fewer complications in the postoperative period when compared with the standard AKA. Retained muscle attachments facilitate increased limb function and allow use of slide joint prosthetics, which are gaining popularity for ambulatory patients. The thickened skin and subcutaneous tissues overlying the patella, and the posterior incision have the potential benefit of protection against trauma and osteomyelitis seen with traditional AKA, in which case the open ended medullary bone is deep to the incision. We believe that for these same reasons the GSA should be considered in the nonambulatory patient as well.

Evaluation of Intraperitoneal and Incisional Bupivacaine or Levobupivacaine for Postoperative Analgesia in Ovariohysterectomized Dogs

Background: Ovariohysterectomy (OHE) is the most commonly performed elective surgical procedure in companion animals. OHE offers benefits of control of population and decreased risk of potentially life-threatening diseases such as mammarian tumours and pyometra. Traditional OHE intervention causes inflammation and pain due to trauma during organ manipulation. The purpose of this study was to compare the effect of intraperitoneal and incisional administration of bupivacaine (BP) or levobupivacaine (LP) on postoperative analgesia in dogs undergoing the OHE procedure.Materials, Methods &amp; Results: A total of 24 mix-breed bitches aged between 1 - 3 years and weighed 19 - 20 kg were used in this study. The animals were divided into three groups as control (n = 8), BP (n = 8) and LP group (n = 8). The animals were kept under surveillance at the hospitalisation unit of the animal hospital for one day before the elective OHE. The dogs were fasted for 12 h before the surgery, with adlib water consumption. Atropine sulphate 0.045 mg/kg was administered subcutaneously approximately 30 min before general anaesthesia. Midazolam (0.3 mg/kg) was intravenously injected into all dogs for pre-anaesthetic medication. After sedation, anaesthesia was induced with propofol (4 mg/kg, IV) and then the dogs were orotracheally intubated using cuffed endotracheal tubes. General anaesthesia was maintained by administration of 2% isoflurane. The ventral abdomen was prepared aseptically for OHE following the general anaesthesia. All animals were operated on by the same surgeon. During surgery, sprayed bupivacaine 0.5% (4.4 mg/kg) with an equal volume of saline in BP group, levobupivacaine 0.5% (4.4 mg/kg) with an equal volume of saline in LP were then applied over the ovaries, uterine broad ligaments and cervix uteri. After removal of the uterine body, either LP or BP was sprayed to left and right, or cranial and caudal parts of the abdominal cavity. Finally, the incision line was sprayed before closing the skin. The control group received only sprayed saline. The pain evaluation was carried out with modified Melbourne pain scoring scale. To determine cortisol concentrations, blood samples were taken before anaesthesia induction (baseline) and postoperative 0, 0.5, 1, 2, 4, 6, 12 and 24 h. Postoperative pain scores were higher in the control group than BP and LP groups following surgery at 30 min, 1st, 4th, and 6th h. In all groups, cortisol levels increased postoperatively, whereas they decreased more rapidly in BP and LP groups. There was a steady increase at postoperative 0 min, 30 min, 1st, 2nd, 4th and 6th h in the control group and at postoperative 0 min, 30 min and 1 h in BP and LP groups (P &lt; 0.05).Discussion: Intraperitoneal and incisional bupivacaine shows significantly superior postoperative pain management benefits after the closure of skin, compared to untreated dogs and it is also superior to lidocaine treatment at 0.5 h following the visual analogy pain assessment system. In the present study, the observation of lower pain scores in BP group at 0.5, 1, 4 and 6 h as compared to the control group was similar to findings of other studies. LP group also showed decreased pain scores at above-mentioned h without any significant difference. However, only in LP group, pain scores at 24 h were lower than postoperative pain scores. In conclusion, it is suggested that sprayed intraperitoneal and incisional BP and LP are very effective for preventing postoperative pain ovariohysterectomized dogs.

Clinical Profile of Patients Undergoing Mass Closure and Layered Closure Techniques in Laparotomies

Background: Linen and Cotton were already in use. Silk was the next suture of choice in non-absorbable suture range. It became very popular because of its excellent handling properties. It was extensively used in all surgical procedures including Cardiovascular Surgery. Halstead was its main proponent. Thorough clinical examination of the patients was made and recorded. Particular attention was given to note the anaemia, nutritional status, jaundice, respiratory tract infections. Apart from the examination of the system involved, routine examination of CVS, RS &amp; CNS were carried out. Subjects and Methods: History taking was followed as a routine in all cases admitted to the wards.Plain X-ray abdomen, Contrast X-rays like barium meal, Upper GI endoscopy and Abdominal ultrasound and CT scan were done in necessary cases.However in emergency cases, only the investigations necessary for supporting the diagnosis were employed. Results: In this study mid line incision was done in 39 patients, 65% of patients, Right Para Median incision in 18 patients 30 %, left Para median in 3 patients, 5%. In this study in mass closure group a mean time taken (min) 15.73 was required for the closure of the incision with standard deviation of 1.82.In the layered closure group mean time taken (min) was 25.03 with a standard deviation of 1.83. Conclusion: The age of the patients ranged from 15-65 years. Out of 60 patients 16 were in the age group of &lt;30 years, 13 were 30-39 years, 11 were 40-49 years and 20 were &gt;50 years.

Safety of drainless excision of the submandibular gland

IntroductionPercutaneous drains can be associated with several complications, including infection, fistula formation, discomfort and prolonged hospitalization. ObjectiveThe aim of this study was to evaluate the safety of submandibular gland excision without the use of surgical drains. MethodsWe analyzed the surgery time, postoperative complications such as bleeding, facial palsy, seroma, and repeat exploration of wounds and duration of the hospital stay. Excision of the submandibular gland via a transcervical approach was undertaken by two surgeons. Prior to wound closure, the skin flap and wound bed were approximated using hemostatic fibrin glue (Greenplast-Q PFS KIT®, GC Greencross, Youngin, Korea). Neither saline irrigation nor insertion of a percutaneous drain were included. ResultsA total of 23 patients underwent submandibular gland excision. The study group consisted of 14 men (60.8%) and 9 women (39.2%) (mean age, 47.6 years; range, 24–70 years). There were two patients who had minor complications. One patient showed minor bleeding on the skin incision line immediately postoperatively, and one developed a seroma at 7 days postoperatively. There were no major surgical complications. Total duration of the surgery from skin incision to closure averaged 44.86minutes. Mean duration of the hospital stay was 3.17 days. Patients were discharged on average at 1.17 days after surgery. ConclusionThe submandibular gland can be safely excised without the use of a surgical drain, therefore allowing early patient discharge.

Breast Cancer in the Transgender Population.

ES is a 41-year-old transgender male who presented to medical oncology as a referral from surgical oncology for T2N0M0 right breast cancer. At that time, he was receiving weekly testosterone injections intramuscularly at 0.25 mg, and had been on this regimen for 7 months. He was planning bilateral mastectomies in the spring. That winter, he palpated a mass in his right breast, and imaging revealed a 2.5-cm hypoechoic mass. A biopsy of the mass revealed invasive ductal carcinoma, with a nuclear grade of 3. His tumor was estrogen receptor positive (H-score of 180), progesterone receptor positive (H-score of 90), androgen receptor positive (H-score of 220), and HER-2/neu positive by FISH, with a Ki-67 of 90%.The clinical experience of ES illustrates challenges common to the sexual and gender minority population. ES presented to the clinic with a female friend. At that time, his name and gender in the electronic medical record (EMR) matched his driver’s license, and not his preferred name or gender. Consequently, when he was called from the waiting room, he was called by his former name.The staff had not been notified of the appropriate name or pronoun to use prior to ES’s arrival, and consequently was associating ES with a female gender, as indicated in the EMR. When the question about menstrual status was addressed, he stated that he had not had a period in 7 months since beginning testosterone treatment. The medical assistant questioned the use of testosterone, and ES had to explain his gender reassignment journey.By the time the physician assistant (PA) entered the room to perform the first part of the shared visit, ES was visibly upset, expressing anger with nonverbal cues. During the conversation, the PA did not acknowledge or establish the relationship of ES’s female friend. The PA did not address the issue of gender identity, the use of testosterone, or plans for reassignment surgery. The physician also deferred discussion of gender reassignment during his portion of the visit and, without asking about gender reassignment, recommended cessation of testosterone therapy. Neoadjuvant docetaxel/cyclophosphamide/trastuzumab/pertuzumab was ordered, and ES agreed to treatment, but declined following the suggestion to stop testosterone.At each treatment visit, ES had to check in at the desk with his former name, resulting in confusion from the staff. With each lab draw, his name and birthdate were confirmed using the former name. With every administration of chemotherapy, double-nurse verification at the chairside was performed by reading his arm band and comparing it to the drug label. For each visit, ES had to use his old name six times. With new staff assigned to him each week, he felt pressured to explain his gender identity to several new people at each visit. At one particular visit, a patient’s family in the next cubicle overheard this conversation, and ES overheard them discussing and laughing about his gender identity. ES dreaded his chemotherapy appointments not just due to the expected toxicity, but also because of the insensitivity toward his chosen gender.ES tolerated chemotherapy and proceeded to surgery. He underwent bilateral mastectomies by the surgical oncologist, who had discussed his gender reassignment with him and had referred him to plastic surgery for co-management of the surgical intervention. The plastic surgery team planned for reconstruction to include skin and soft-tissue rearrangement to give an incision line along the lower border of the pectoralis for better male cosmetic outcomes. Together, they performed bilateral mastectomies with right sentinel lymph node biopsy, horizontal mastopexy, and nipple-areolar grafting. Ultimately, the pathology revealed a complete response, and ES was pleased with the cosmetic outcome.ES was then started on tamoxifen. Again it was suggested that he discontinue testosterone therapy. He determined that he was more comfortable with an increased risk of recurrence than he was with feminine physical characteristics and chose to continue testosterone. After 6 weeks of tamoxifen, his menses resumed. He elected to discontinue tamoxifen. He had no more vaginal bleeding after that episode. He was referred for bilateral salpingo-oopherectomy (BSO), with the intent to treat with an aromatase inhibitor. He proceeded with BSO and opted against the aromatase inhibitor, citing concerns about unknown interactions with gender-affirming medication. He completed 1 year of trastuzumab (Herceptin) and continued surveillance visits.

Effect of three-layer close suture and Allgöwer-Donati suture on incision healing after calcaneal fracture surgery

Objective To compare the efficacy between three-layer suture and Allgower-Donati suture on wound healing. Methods From September 2016 to June 2018, patients with Sanders type III calcaneal fracture were randomly divided into two groups: three-layer close suture group (26 cases, 18 males and 8 females, aged 19-48 years, with an average age of 33.69±8.84 years) and Allgower-Donati group (26 cases, 19 males and 7 females, aged 19-49 years, with an average age of 32.38±8.45 years). The traditional L-shaped incision was used in all patients. The inflammatory reaction area of incision, skin temperature change at the corner of L-shaped incision line and the healing grade of incision were compared between the two groups. Results 52 pa-tients were followed up for 6 months. At 2 weeks after operation, the inflammatory reaction area of incision skin in the three-layer close skin suture group (26.46±9.37 mm2) was smaller than that in Allgower-Donati suture group (33.16±9.33 mm2). There was a significant difference between the two groups (t=2.584, P=0.013). There was no difference in skin temperature at the corner of L-shaped incision between the two groups before and on the first day after operation. However, the incision skin temperature of the three-layer close suture group on the 2nd and 3rd day after operation[ (36.47±0.33) ℃ and (36.54±0.22) ℃]was higher than that of Allgower-Donati group[ (36.20±0.42) ℃ and (36.22±0.43) ℃]. The difference was statistically significant (t=2.61, P=0.01; t= 3.48, P=0.001). There were 25 cases of Class A healing and 1 case of Class B healing in three-layer close suture group, with Class A healing rate of 96.15% (25/26). In Allgower-Donati group, there were 22 cases of Class A healing, 1 case of Class B healing, and 3 cases of Class C healing, with Class A healing rate of 84.62% (22/26). Among all grade B healing incisions, 1 case had a small amount of local hemorrhagic exudation in the three-layer close suture group, while 1 case had a black necrosis at the edge of the in-cision, 3 cases had a purulent incision and exposed steel plate in the Allgower-Donati group. Conclusion In the treatment of L-shaped incision of calcaneal fracture, three-layer close suture is a better method than Allgower-Donati suture because of smaller in-flammatory reaction area of incision, higher skin temperature change at the corner of L-shaped incision on the 2nd and 3rd day af-ter operation, higher rate of first-degree healing of incision and slighter incision complications. Key words: Calcaneus; Fractures, bone; Wound closure techniques; Wound healing

Minimal Scar Formation After Orthopaedic Skin Incisions Along Main Folding Lines.

Patients, particularly those who are young, often develop noticeable orthopaedic scars. In order to achieve minimal scarring, surgeons should attempt to place incisions in skinfolds or skin creases. Optimal incision lines can be determined from the direction of stretch marks (striae distensae), which develop perpendicular to lines of tension or main folding lines. A composite diagram of photographs of 213 individuals with striae distensae was created and compared with 276 images of incisions and scars derived from the Internet. Classically described Langer cleavage lines often run counter to real tension lines and poorly predict the optimal direction for skin incisions. Whenever possible, main folding lines should be utilized as a guide in planning surgical incisions for young patients as well as for correction of problem scars.

A suitable marking method to achieve lateral margin negative in endoscopic submucosal dissection for undifferentiated-type early gastric cancer.

Background and study aims Delineating undifferentiated-type early gastric cancer (UD-type EGC) from noncancerous areas is difficult. Therefore, the lateral margin negative (LM−) resection rate of endoscopic submucosal dissection (ESD) is lower for UD-type EGC than for differentiated-type EGC. This study aimed to retrospectively evaluate the effectiveness of the marking methods with circumferential biopsies in ESD for UD-type EGC. Patients and methods We analyzed the clinical outcomes of ESD in 127 patients with UD-type EGC between April 2013 and 2017. We performed diagnostic delineation of cancerous areas using magnifying endoscopy with narrow-band imaging, and four or more circumferential biopsies approximately 5 mm apart from the estimated lesion border were obtained to confirm noncancerous areas. The markings were placed on the circumferential biopsy scars, and a mucosal incision line was made outside the markings. Results Median size of the tumors and ESD specimens was 12 and 35 mm, respectively. En-bloc resection rate was 100 % (127/127), and LM− and curative resection rates were 97.6 % (124/127) and 80.3 % (102/127), respectively. Circumferential biopsy in preoperative esophagogastroduodenoscopy has successfully identified the misdiagnosis of cancerous areas of four patients (3.2 %), with three (2.4%) achieving LM− resection. LM + resection was pathologically identified in three patients (2.4 %), with all undergoing non-curative resection due to > 20-mm tumor. The proportion of patients with the shortest distance ≥ 5 mm from the lesion edge to the specimen edge was 88.2 % (112/127). Conclusion Our marking methods with circumferential biopsies may reduce LM + resections in ESD for UD-type EGC.