Tumescent Infiltration Research Articles

Deep Back Liposuction: Ultrasound-Guided Deep Fat Liposuction of the Subiliac Crest.

Aesthetic surgery of the buttock has evolved substantially in the last 5 years, including technologies such as ultrasound to achieve safer and more aesthetic results and aesthetic techniques not only for buttock fat infiltration, but also for modeling the gluteal frame. This study describes the technique of ultrasound-guided subiliac crest deep-fat liposuction for contouring the buttock-back region. This area is often overlooked in gluteal frame management because of the depth at which it is located. Healthy patients were chosen for whom this deep back ultrasound technique was performed to improve the gluteal frame. The technique involved making a small incision in the iliac crest of the ilium, followed by identification of the area of deep posterior fat below the iliac crest under ultrasonographic control. A cannula was positioned to perform static tumescent infiltration and liposuction was performed. This study included 16 female patients aged 20 to 45 years old who underwent this procedure. The infiltrated solution in this area was 150 to 200 cc of tumescent solution per side, and a 175-200 cc volume of fat was obtained. The depth of the study area varied. However, we observed that it was generally located between 3 and 5 cm from the skin. This study indicates that this technique is safe and effective in achieving aspiration of the subiliac crest deep fat, which enhances the frame for buttock-back contouring. Ultrasound was indispensable to locate the fat and infiltrate the area for subsequent liposuction.

Adoption of the Wide-Awake Local Anesthesia No Tourniquet Technique in Hand Surgery

» Wide-awake local anesthesia no tourniquet (WALANT) technique featuring tumescent infiltration of lidocaine with epinephrine at the operative site has broad application in hand surgery including both soft-tissue and bone procedures.» The advantages of wide-awake anesthesia include high patient satisfaction, preserved intraoperative finger and wrist motion, cost-effectiveness, improved operating room efficiency, fewer opioids during recovery, and improved access to hand surgery, which may be performed in an office-based setting without the need for anesthesia personnel.» In properly selected patients, use of lidocaine with epinephrine in the hand and fingers is safe. Rare postprocedure digital ischemia may be effectively treated with phentolamine rescue.» Barriers to adopting wide-awake anesthesia may be overcome by educating resistant stakeholders, including hospital administrators, nurse leaders, and anesthesia colleagues, about the advantages of the WALANT method.» The risk of postoperative complications after hand procedures may be mitigated by using the wide-awake technique instead of regional anesthesia with sedation or general anesthesia.

Factors Affecting Postoperative Complications of Suction-Curettage by Arthroscopic Shaver for Bromhidrosis.

Suction-curettage by arthroscopic shaver is the most effective treatment for bromhidrosis; however, postoperative complications require wound management and exhibit a high risk of hypertrophic scarring. We investigated factors affecting postoperative complications. We retrospectively evaluated data for 215 patients (430 axillae) with bromhidrosis treated with suction-curettage by arthroscopic shaver between 2011 and 2019. Cases followed for less than 1 year were excluded. Complications of hematoma or seroma, epidermis decortication, skin necrosis, and infection were recorded. Multinomial logistic analysis was used to calculate odds ratios and corresponding 95% confidence intervals for the complication of the surgery, adjusting for relevant statistically significant variables. Complications occurred in 52 axillae (12.1%). Epidermis decortication occurred in 24 axillae (5.6%), with a significant difference for age (P < 0.001). Hematoma occurred in 10 axillae (2.3%) with a significant difference in tumescent infiltration use (P = 0.039). Skin necrosis occurred in 16 axillae (3.7%) with a significant difference for age (P = 0.001). Infection occurred in 2 axillae (0.5%). Severe scarring occurred in 15 axillae (3.5%), with complications related to more severe skin scarring (P < 0.05). Older age was a risk factor for complications. Use of tumescent infiltration resulted in good postoperative pain control and less hematoma. Patients with complications presented with more severe skin scarring, but none experienced limited range of motion after massage.

Fluid Balance After Tumescent Infiltration: A Practical Guideline to Avoid Dilution Anemia in Circumferential Liposuction Based on a Prospective Single-Center Study.

Circumferential liposuction may cause dilution anemia due to a high volume of infiltrated tumescent. Studies analyzing the percentage of absorbed tumescent and the safe limit of tumescent infiltration are currently lacking. The aim of this study was to calculate the average volume uptake of administered fluids in power-assisted liposuction, and to calculate a practical formula to determine the amount of fluid that can safely be administered without inducing symptomatic dilution anemia or hypervolemia. Patients undergoing circumferential liposuction with power-assisted tumescent infiltration were included in a prospective clinical study. All relevant administered and excreted volumes during and after the operation were collected. Preoperative vs postoperative hemogram results were compared and the hemodynamic parameters were followed for 24 hours. The average volume uptake was calculated based on the measured volumes, and on the ratio between administered volumes and the patient's blood volume. Thirty patients were included during September 2021. The average volume uptake was 58% for a calculated 1.11:1 infiltration to aspiration ratio. There was a mean drop of 1.9 g/dL and 4.6% for the postoperative hemoglobin and hematocrit, respectively, with a stable red blood cell level. All patients remained hemodynamically stable without the need for blood transfusion or prolonged oxygen administration. The average tumescent vs blood volume ratio was 85.0%. In circumferential liposuction with power-assisted infiltration, the infiltrated tumescent volume should remain below 85% of the patient's blood volume to minimize the risk of symptomatic dilution anemia or hypervolemia.

Simultaneous Separation and Tumescence: A New Paradigm for Liposuction Donor Site Preparation.

An ever-increasing demand for liposuction and fat transplantation procedures in the United States reflects their continued safety and clinical effectiveness. Technical breakthroughs, such as the utilization of tumescent infiltration and fat separation techniques, have been instrumental in optimizing outcomes but add time to the surgical procedure. Simultaneous separation and tumescence (SST) is a new technique combining these innovations to further improve safety and efficiency in liposuction. The authors describe their technique for utilizing SST on more than 1200 patients spanning a 6-year period. A split abdomen study was designed to compare the vasoconstrictive effectiveness of SST with traditional Klein infiltration techniques. A quantification perfusion analysis utilizing indocyanine green angiography was performed on 4 patients to illustrate the vasoconstrictive effectiveness of SST over traditional Klein infiltration techniques. A mean relative vasoconstriction score was calculated relative to the umbilicus for each technique. Compared with traditional Klein tumescence techniques, SST has a similar complication rate, utilizes similar infiltrative volumes, and increases vasoconstriction (mean 89.6% SST hemiabdomen vs 48.1% Klein hemiabdomen at 2 minutes, P < 0.0001). SST represents a novel, long-overdue departure from Klein tumescence, which has been a valuable mainstay for donor site preparation for over 3 decades. SST will pave the way for more efficient operative times and potentially higher volumes of fat being safely extracted.

Comparing the Efficiency of Tumescent Infiltration Techniques in Burn Surgery.

Tangential excision and grafting of burn wounds result in significant intraoperative blood loss, and infiltration of a dilute epinephrine solution (tumescence) is routinely performed to reduce such bleeding. Tumescent infiltration has been described using both a manual technique (syringe) and a pump device. The purpose of this study is to compare the efficiency of these two methods in terms of time and economy of motion. Consecutive adult burn patients at a single center requiring excision and grafting were enrolled in the study and randomized into either the manual or pump technique. Excisions involving less than 2% TBSA were excluded, along with specific anatomic regions (eg, head and neck). Infiltration with epinephrine solution (1:500,000) was performed to the endpoint of tumescence by a single surgeon and filmed/coded for duration, number of maneuvers, and volume of tumescence injected. Fourteen patients were enrolled, and 16 cases were randomized to either manual (N = 8) or pump infiltration (N = 8). The pump method required less time (2.0 vs 1.1 cm2/s, P < .001) and fewer maneuvers (37.8 vs 1.1 cm2/move, P < .001) to reach the desired endpoint of tumescence. Use of the infiltration pump also resulted in a reduced volume of tumescent fluid required to reach this point of tumescence (1.7 vs 2.4 mL/cm2, P = .01). Compared to the manual technique, an infiltration pump was significantly more efficient in terms of both time and economy of motion. These reductions are potentially useful for improving operating room efficiency as well as minimizing operator fatigue.

801 Topical hemostatic agents in burn surgery: a systematic review

IntroductionAcute burn surgery (tangential excision and grafting) has long been associated with significant intra-operative bleeding over large surface areas, where in adults approximately 200-250 mL of blood loss would be expected per %TBSA excised and grafted using traditional methods. Several techniques were introduced to limit bleeding, including tourniquets, tumescent infiltration, and topical agents. To date, no study has comprehensively investigated the available data regarding topical hemostatic agents in burn surgery.MethodsA systematic review was performed by two independent reviewers using PubMed, Scopus, and Web of Science databases from first available to September 10, 2021. Articles were included if they were published in English and described or evaluated topical hemostatic agents used in acute burn surgery (excision and/or grafting). Animal studies and review articles were excluded. Data was extracted on the topical agent(s) used, their dosage, mode of delivery, hemostasis outcomes (if measured), and complications (if reported).ResultsThe search identified 1982 non-duplicate citations, of which 134 underwent full text review, and 49 met inclusion criteria. Papers were grouped whether they compared (n=11, 22%), described (n=21, 43%) or secondarily described (n=17, 35%) topical hemostatic agents. Several authors (n=22, 45%) described topical hemostatics as part of a protocol that included other methods of blood conservation (tourniquet, tumescent infiltration, etc). In total, 31 studies incorporated a vasoconstrictor agent (epinephrine, phenylephrine, vasopressin), and 30 studies incorporated a procoagulant agent (thrombin, fibrin). Four studies incorporated other agents (hydrogen peroxide, tranexamic acid and collagen). The most common vasoconstrictor used was epinephrine, with doses ranging from 1:1,000 to 1:1,000,000. The most common procoagulant used was thrombin, with doses ranging from 10 to 1000 IU/mL. Among the comparative studies, outcomes of blood loss were not reported in a consistent manner, therefore meta-analysis could not be performed. The majority of studies (94%) were level of evidence III to V.ConclusionsA multitude of topical hemostatic agents have been reported in the burn literature, with a wide range of dosages and modes of deliveries, as well as protocolization with other blood conservation techniques to limit blood loss during surgery. Determining the optimal topical hemostatic agent is limited by low quality data and challenges with consistent reporting of intra-operative blood loss and other clinically meaningful outcomes.

87 Comparing the Efficiency of Tumescent Infiltration Techniques in Burn Surgery

IntroductionTangential excision and grafting of burn wounds results in significant intra-operative blood loss. Infiltration of a dilute epinephrine solution is routinely performed to reduce bleeding from both the eschar and donor sites. Tumescence infiltration has been described using both a manual technique or a pump device. The purpose of this study is to compare the efficiency of these two methods in terms of time and economy of motion.MethodsConsecutive adult burn patients who required excision and grafting were enrolled in the study. Manual infiltration consisted of an aspirating syringe (10 mL), spinal needle (18 gauge), and three-way stopcock connected to sterile tubing. Pump infiltration consisted of a blunt cannula and infiltration pump (300 mL/minute). Prior to each case, patients were randomized into either the manual or pump tumescent technique. Excisions of < 2% TBSA were excluded, along with specific anatomic regions (head and neck, genitalia, hands and forearms, feet, and legs below the knee). Infiltration with epinephrine-saline solution (1:500,000) was performed to the endpoint of tissue tumescence by a single surgeon for consistency. ImageJ software was used to calculate the surface area to be infiltrated. The infiltration was filmed and later coded for duration, number of maneuvers, and total volume of tumescence injected. Any complications related to the infiltration of tumescence were collected.ResultsA total of 14 patients were enrolled, and 16 cases were randomized to either manual (N=8) or pump infiltration (N=8). Participants were 71% male, with a mean age of 41.8 years, and mean burn size of 16.9% TBSA. The pump method required less time (2.0 cm2/s vs 1.1 cm2/s, p< 0.001) and fewer maneuvers (37.8 cm2/move vs 1.1 cm2/move, p< 0.001). Use of the infiltration pump also resulted in a reduced volume of fluid required to reach the endpoint of tumescence (1.7 mL/cm2 vs 2.4 mL/cm2, p=0.01). No complications were reported related to the process of tumescence in either group.ConclusionsCompared to the manual technique, use an infiltration pump was significantly more efficacious in terms of both time and economy of motion. Additionally, less fluid volume was required to achieve the endpoint of tumescence.

Radiofrequency ablation of varicose veins: experience at a tertiary hospital

Background and objectives: Radiofrequency ablation (RFA) is a recent modality of treatment of the affected varicose vein. In the present study, the outcome of great saphenous varicose vein disease treated by radiofrequency ablation technique was analyzed.&#x0D; Methods: Patients with varicosities of the lower limb affecting mainly the great saphenous vein were (GSV) included. The procedures were carried out under spinal anesthesia. The target varicose vein was accessed by Seldinger technique and the RFA catheter advanced 2 to 3 cm below sapheno-femoral junction under ultrasonography (USG) guidance. A tumescent anesthetic infiltration was given in a solution of normal saline and sodium bicarbonate before the vein being ablated.&#x0D; Results: The success rate of RFA was 97.5 % (39 out of 40). One patient showed episodic recanalisation of vein at one year duplex colour scan. Though the complications related to procedure were negligible, one patient developed endovenous heat induced thrombosis (EHIT) and non-fatal pulmonary thromboembolism (PTE) which was managed adequately.&#x0D; Conclusion: Endovenous RFA is a useful treatment modality for varicose vein disease primarily due to great saphenous insufficiency with marked symptomatic improvement and least recurrence. Although the complications are minimal, EHIT is a potential and serious complication of heat ablation.&#x0D; Ibrahim Med. Coll. J. 2021; 15(1): 37-40

Commentary on: Safety of Large Volume Liposuction in Aesthetic Surgery: A Systematic Review and Meta-Analysis.

Kanapathy et al1 did an excellent review of large volume liposuction. Liposuction is one of the most common surgical procedures in plastic surgery,2 and it has evolved a lot both in how it is performed and the technology employed. One of the most important aspects in the evolution of the technique, in addition to the technologies utilized, has been the volume of fat removed during the surgical procedure. Initially, liposuction was created for the elimination of small volumes of fat located in specific areas.3 However, advances in technology and surgical techniques allowed increasing the amount of fat removed. The first reports of large volume liposuction had as their main limitation the significant bleeding that occurred during surgery, which usually required multiple blood transfusions to perform.4,5 With the advent of tumescent infiltration, the bleeding problem was resolved,6-8 thereby leading to the possibility of increasing...

Efficacy of Topical Tranexamic Acid (Cyclokapron) in "Wet" Field Infiltration with Dilute Local Anaesthetic Solutions in Plastic Surgery.

Surgical bleeding may lead to the need for blood transfusion and minimizing blood loss has been a basic principle followed by surgeons for generations. Antifibrinolytic agents are widely used to reduce perioperative haemorrhage. The present study sought to assess the efficacy of directly infiltrated tranexamic acid in ameliorating bruising in participants undergoing cosmetic plastic surgery (liposuction). The study employed a blinded, prospective, randomized, case control design. Thirty-three patients were studied. Tranexamic acid free infiltration tumescent solution (saline, bupivacaine lignocaine and adrenalin) was infiltrated to one flank of patients undergoing liposuction of flanks. The other flank was infiltrated with the same tumescent solution (saline, bupivacaine lignocaine and adrenalin) mixed with tranexamic acid (0.1%). Bruises were photographed one and seven days after surgery and measured for size. The surface area of the bruises was calculated using ImageJ software. We compared the bruised surface are between the tranexamic acid infiltrated flank and non-tranexamic acid infiltrated flank in the same patient. The model employed involved measuring the bruises on each flank of the same patient, with surgery by a single surgeon using the same infiltration and surgical techniques for both sides. The only variable was the difference in tranexamic acid concentration between study and control flanks. We found that use of tranexamic acid consistently resulted in a smaller bruise area on days one and seven after liposuction of flanks. Results were statistically significant. This is the first study examining addition of tranexamic acid to a tumescent infiltration solution-to produce a predictable local concentration of tranexamic acid-in order to maximize surgical site effect and minimize systemic effect. The authors recommend incorporation of tranexamic acid as a routine component along with adrenaline and local anaesthetics in tumescent field infiltration solution 10-15min before commencement of the cosmetic surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Factors Affecting the Efficacy of Suction Curettage Using an Arthroscopic Shaver for Bromhidrosis.

Suction-curettage using an arthroscopic shaver is the most effective surgical treatment for bromhidrosis; however, information regarding the procedure is limited. This study investigated the factors that affect the efficacy of suction-curettage. We retrospectively evaluated data for 215 patients (430 axillae) with bromhidrosis treated with suction-curettage using an arthroscopic shaver between 2011 and 2019. Excellent or good efficacy with improved malodor was achieved in 418 axillae (97.21%). Secondary suction-curettage was performed for 11 (2.56%), with excellent results. Efficacy and need for secondary suction-curettage were not associated with age, sex, shaving time, and tumescent infiltration use. Complications were observed in 52 (12.09%) axillae, including hematoma or seroma, epidermis decortication, skin necrosis, and infections; 10 (2.33%) required local debridement for wounds. Complications showed a significant difference with respect to age (p < .001). Pain scores on postoperative Day 2 were significantly lower for patients treated using tumescent infiltration than those for the others (1.65 ± 0.84 vs 4.57 ± 1.16; p < .001). The results suggest that 7 to 15 minutes of suction curettage using an arthroscopic shaver is sufficient to achieve good efficacy for bromhidrosis with few complications. Older age was a risk factor for complications, and tumescent infiltration use achieved good postoperative pain control. II.

The Value of Tumescent Infiltration in Bilateral Breast Reduction: Optimizing Vasoconstriction.

Background:Surgical adjuncts should improve surgical outcomes but should not increase complications. Epinephrine reduces bleeding in breast reduction, but various doses and volumes have been used. The ideal dose of epinephrine is still debated. The aim of this study was to assess blood loss after infiltration of 1 L of tumescent fluid containing epinephrine at a concentration of 1 in 100,000 (1 in 105) and 1200 mg of lignocaine in patients undergoing bilateral breast reduction.Methods:Thirty-three consecutive patients undergoing bilateral breast reduction were included in the study. Data captured included age, mass of tissue removed, volume of blood loss, and surgical complications, especially hematoma formation.Results:The mean age was 41 years (range, 17–74 years). The mean mass of tissue removed was 786 g (range, 307–1339 g). The mean total blood loss was 76 mL (range, 50–200 mL)—that is, 38 mL per side. One patient presented with a unilateral swelling and pain after 48 hours and underwent exploration. A venous pool of <100 mL of blood was evacuated. One patient suffered bilateral nipple loss of >50%, and another patient suffered loss of 30%. The mean follow-up is 9 months (range, 2–20).Conclusion:One liter of Ringer’s lactate containing epinephrine at a concentration of 1 in 105, when injected into the breasts (500 mL per breast) before breast reduction, results in a massive reduction in blood loss.

Diffuse large B cell lymphoma in a preceding IgG4-related disease with kidney restricted lambda light chain expression: case report and literature review

BackgroundIgG4-related disease (IgG4-RD) is a newly classified but poorly understood immune-medicated systemic disease. It causes potential fibroinflammation in one or more organs, characterized by tumescent organs and marked IgG4-positive plasma cells infiltration in the affected tissues. There have been a few cases revealing close relationship between IgG4-RD and formation of B cell lymphoma. Diffuse large B cell lymphoma (DLBCL) and extranodal marginal zone lymphoma (EMZL) of mucosa-associated lymphoid tissue are the most common sub-types ever described, whereas the exact mechanism remain unclear.Case presentationWe report a 64-year old Chinese male who presented chronic kidney disease and was initially diagnosed typical IgG4-RD. Pathological findings revealed there was restricted expression of lambda light chain in the kidney. There was also elevated uptake abnormality observed in 18F-FDG-PET/CT. Prednisone combined with oral cyclophosphamide helped the patient to get a partial remission of renal function and an obvious decrease of IgG4 level. However, he developed DLBCL 16 months after IgG4-RD diagnosis. The DLBCL is speculated to transform from a pre-existing but possible missed diagnosed EMZL.ConclusionsConcurrent IgG4-RD with kidney-origin EMZL developing DLBCL has never been reported in the literature. Clinicians should keep in mind that lymphoma may occur in IgG4-RD. The mechanism of lymphomagenesis potential in IgG4-RD needs further study.

Effect of Tumescent Lidocaine and Epinephrine Infiltration on Blood Loss in Inferior Pedicle Wise-Pattern Breast Reduction: A Prospective Randomized Study.

The idea of infiltrating epinephrine-containing solution in reduction mammoplasty with the aim of reducing blood loss dates back to 1985. Although its use is fairly common among surgeons, scientific evidence supporting such use has been feeble and inconsistent. Therefore, we aimed to investigate the effects of tumescent infiltration of lidocaine- and epinephrine-containing solution on blood loss in reduction mammoplasty. A prospective, randomized, double-blinded study is planned. Forty patients admitted to our clinic for mammary hypertrophy are randomly assigned to experiment and control groups, each of a size of 20 patients. Control group underwent conventional Wise-pattern, inferior pedicle breast reduction, whereas experiment group received tumescent fluid infiltration 20min prior to making of the incisions. Data including age, body mass index (BMI), comorbidities, operative time, length of hospitalization along with preoperative, postoperative 2nd and 12th hour complete blood counts are recorded for each patient and compared between groups. Data analysis showed no significant difference between groups in terms of age, BMI, comorbidities or preoperative hematocrit levels. Operative time and hospitalization were significantly shorter in experiment group (p < 0.05*). The drop in hematocrit level in both the 2nd (4.93 ± 2.44% to 15.53 ± 7.17%) and 12th hour (9.4 ± 6.79 compared to 21.28 ± 10.15) was lower in the experiment group (p < 0.01*). A multiple variate analysis incorporating preoperative, postoperative 2nd and 12th hour hematocrit levels demonstrated a significant reduction in blood loss with the use of tumescent infiltration (Wilks' lambda F = 12.84, p < 0.01*). Multiple regression analysis revealed age, BMI, comorbidities, preoperative hematocrit levels and hospitalization did not affect postoperative blood loss (p > 0.05). Duration of operation, however, seemed to affect amount of blood loss postoperatively (p < 0.05*). With outcomes obtained from this study, it is clearly shown that tumescent infiltration significantly reduces blood loss in Wise-pattern, inferior pedicle breast reduction. Furthermore, tumescent infiltration is also shown to decrease operative time and length of hospital stay. EBM LEVEL II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

NTNT Methods – Efficacy and Safety Issue

AbstractThe management of elimination of the pathological reflux in the saphenous vein has been developed recently by introducing the endovenous thermal techniques (EVTA), which have become the first line treatment. However, thermal techniques require tumescent infiltration, what may be the cause of discomfort. Furthermore, the use of EVTA has a potential risk of thermal damage of superficial nerves and requires to wear stocking after the procedure.Non-thermal non-tumescent techniques (NTNT) were proposed as a valid, safe and effective alternative to EVTA with significant clinical improvement, high complete occlusion rate and high posttreatment patient satisfaction. The most common novel NTNT are catheter-directed cyanoacrylate adhesive closure (CAC) and mechanochemical ablation.In the paper an overview of the currently available data regarding the NTNT efficacy and safety are presented.Based on the literature, NTNT has a high efficacy, comparable with the EVTA techniques, with an acceptable risk increase. However further studies with long-term results are needed also with regard to safety aspects.

Liposuction: Drains, Are They Adequate?

Background:Seroma following liposuction (especially mega-sessions; more than 5 L) is a common complication that causes much distress to the surgeon and the patient. This will eventually affect the overall satisfaction and patient’s experience regarding liposuction. If not detected promptly, seromas can impair the results.Methods:This is a prospective analysis performed by the authors in a private practice. All our patients had mega-liposuction sessions (more than 5 L, range 8–12 L) using Power-assisted Liposuction with Lipomatic by Euromai and VASER. Tumescent infiltration was used. Fifty male patients participated after providing their informed consent. Their mean age was 35 years (range, 21–50) and mean body mass index was 29 (range, 28–33). Patients were divided into 2 groups. Group A consisted of 25 patients with no adjunctive draining procedures done, and group B consisted of 25 patients with drainage procedures done. Patients were followed up every other day for 3 weeks for detection of seroma.Results:Seventeen patients had post-operative seroma: 13 in group A and 4 in group B. The volume of seromas was further subdivided into mild (<50 cc), moderate (50–100 cc), and severe (>100 cc).Conclusions:High definition liposuction is a demanding procedure by both the surgeon and the patient to achieve the best results and contour. Drainage procedures and drains placement are truly effective methods for minimizing seroma formation, enhancing the recovery, and eventually improving the results.

Total intravenous anaesthesia with tumescent infiltration anaesthesia without definitive airway for early excision and skin grafting in a major burn - A prospective observational study.

Background and Aims:Patients with major burns posted for early tangential excision and skin grafting pose peculiar challenges for anaesthesiologists. The purpose of the study was to assess safety and efficacy of total intravenous anaesthesia (TIVA) with tumescent infiltration anaesthesia (TIA) for these burn procedures.Methods:This observational single-arm study was conducted on 48 cases of a tertiary centre burn unit, requiring early tangential excision and skin grafting between third and fifth days of burn injury. TIVA was administered using a combination of intravenous (iv) infusion of injection dexmedetomidine and iv boluses of fentanyl, ketamine, propofol, midazolam and paracetamol. TIA was administered in burn wounds after aseptic preparation. Spontaneous breathing was maintained with oxygen supplementation. Haemodynamic and respiratory monitoring was done intraoperatively every 15 minutes and for 6 hours postoperatively. Modified Aldrete's score was calculated at 10 minutes after completion of surgery. Statistical analysis was done using statistical package for the social science software (version 16). Descriptive statistics were used for quantitative variables.Results:Baseline mean HR was 106.95 ± 11.17 bpm (beats per minute). HR settled at 73.17 ± 6.97 bpm during the intraoperative period. The baseline mean arterial pressure (MAP) of 82.42 ± 10.04 mmHg was maintained at 81 ± 7.32 mmHg during the intraoperative period. In all, 95.8% achieved early recovery with mean modified Aldrete's score of ≥9 at 10 minutes post-surgery. There was no episode of apnoea or desaturation.Conclusion:TIVA in combination with TIA minimally interferes with homeostasis and promotes early recovery in patients undergoing early excision and grafting in major burns.

Gliding Brow Lift (GBL): A New Concept.

Creating the ideal aesthetic eyebrow shape and position is an important goal in facial rejuvenation. One challenge of an eyebrow lift is to find a predictable procedure that balances the advantages and disadvantages of the available strategies. The gliding brow lifting (GBL) is a technique that provides minimal incisions, an effective and stable eyebrow lift, and offers the advantage of precise reshaping of the eyebrow. In a retrospective review, 124 patients, who underwent GBL technique from November 2015 through April 2016, were evaluated. With minimal incisions and tumescent infiltration, the subcutaneous plane of the forehead, eyebrows and temporal face is undermined releasing the skin from the underlying frontalis muscle, orbicularis oculi muscle, corrugator muscle and temporal parietal fascia. Fixation of the repositioned and reshaped eyebrow is achieved with the use of a hemostatic net for temporary cutaneous fixation. The average follow-up period was 17months. Adequate brow repositioning and/or reshaping was achieved in 118 patients. Six patients had bilateral or unilateral recurrence of ptosis. Of these patients with recurrence, four patients had the same procedure re-performed within 1month postoperatively with successful repositioning and/or reshaping of their brow. There was no incidence of hematoma, seroma, infection, permanent sensory changes, motor dysfunction, skin flap necrosis or alopecia. The "gliding brow lifting" (GBL), which combines subcutaneous frontal undermining with minimal incisions, elevation and reshaping of eyebrow and use of a temporary cutaneous fixation with hemostatic net (Net), allows effective, long-lasting results with low rates of complications and satisfactory results. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The safety of one-per-mil tumescent infiltration into tissue that has survived ischemia.

BackgroundThe aim of this study was to assess the safety of one-per-mil tumescent injections into viable skin flaps that had survived an ischemic insult, in order to assess the potential suitability of one-per-mil tumescent injections in future secondary reconstructive procedures such as flap revision and refinements after replantation.MethodsForty groin flaps harvested from 20 healthy Wistar rats weighing 220 to 270 g were subjected to acute ischemia by clamping the pedicle for 15 minutes. All flaps showing total survival on the 7th postoperative day were randomly divided into group A (one-per-mil tumescent infiltration; n=14), group B (normal saline infiltration; n=13), and group C (control, with no infiltration; n=13) before being re-elevated. Transcutaneous oxygen tension (TcPO2) was measured before and after infiltration, and changes in TcPO2 were statistically analyzed using analysis of variance, the paired t-test, and the independent t-test. The viability of flaps was also assessed using the Analyzing Digital Images software at 7 days after the second elevation.ResultsThirty-nine flaps survived to the final assessment, with the sole exception of a flap from group A that did not survive the first elevation. TcPO2 readings showed significant decreases (P<0.05) following both one-per-mil tumescent (99.9±5.7 mmHg vs. 37.2±6.3 mmHg) and normal saline (103±8.5 mmHg vs. 48.7±5.9 mmHg) infiltration. Moreover, all groin flaps survived with no signs of tissue necrosis.ConclusionsOne-per-mil tumescent infiltration into groin flap tissue that had survived ischemia did not result in tissue necrosis, although the flaps experienced a significant decrease of cutaneous oxygenation.