Plastic and reconstructive surgery
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Plast. Reconstr. Surg. · Oct 2014
Putting it all together: recommendations for improving pain management in plastic surgical procedures: hand surgery.
Approaches to upper extremity anesthesia in hand surgery include regional blocks, wide-awake hand surgery with local anesthesia, and stellate ganglion blocks. ⋯ Pain management in hand surgery can be achieved through regional blocks and wide-awake techniques that do not necessitate general anesthesia in an effort to improve safety, convenience, cost savings, and efficiency.
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Plast. Reconstr. Surg. · Oct 2014
Preemptive, preventive, multimodal analgesia: what do they really mean?
To improve postoperative pain management, several concepts have been developed, including preemptive analgesia, preventive analgesia, and multimodal analgesia. This article will discuss the role of these concepts in improving perioperative pain management. Preemptive analgesia refers to the administration of an analgesic treatment before the surgical insult or tissue injury. ⋯ These drugs may be administered via the same route or by different routes. Thus, the aim of multimodal analgesia is to improve pain relief while reducing opioid requirements and opioid-related adverse effects. Analgesic modalities currently available for postoperative pain control include opioids, local anesthetic techniques [local anesthetic infiltration, peripheral nerve blocks, and neuraxial blocks (epidural and paravertebral)], acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2-specific inhibitors as well as analgesic adjuncts such as steroids, ketamine, α-2 agonists, and anticonvulsants.
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Opioids remain the most common analgesic tool for the surgeon, owing to their cost-effectiveness in both the inpatient and outpatient setting. Aside from these attributes, opioids have significant side effects that are associated with morbidity and mortality. Specifically, obese patients, patients with sleep apnea, and the elderly may be at an increased risk of experiencing sedation and respiratory depression in response to opioids. ⋯ These clinical scenarios are associated with extreme challenges in postoperative analgesic management. With all opioid prescribing, other sedative medications should be limited or avoided as the risk for additive sedation is significant. This review aims to describe systematic methods to reduce opioid side effects and identify specific risk-reduction strategies within each risk group.
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Plast. Reconstr. Surg. · Oct 2014
Nonendoscopic deactivation of nerve triggers in migraine headache patients: surgical technique and outcomes.
Low efficacy, significant side effects, and refractory patients often limit the medical treatment of migraine headache. However, new surgical options have emerged. Dr. Bahman Guyuron and others report response rates between 68 and 95 percent after surgical deactivation of migraine trigger sites in select patients. In an effort to replicate and expand migraine trigger-site deactivation surgery as a treatment option, the authors' group and others have developed nonendoscopic algorithms. The exclusion of endoscopic techniques may be useful for surgeons with little experience or limited access to the endoscope and in patients with challenging anatomy. ⋯ Therapeutic, IV.
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Plast. Reconstr. Surg. · Oct 2014
Case ReportsThe volar forearm fasciocutaneous extension: a strategy to maximize vascular outflow in post-burn injury hand transplantation.
Patients with circumferential extremity burns may have a deficiency of cutaneous veins, which presents a challenge for both autologous reconstruction and vascularized composite allotransplantation. The authors present a 44-year-old, left-hand-dominant man with metacarpal level amputation of his left hand secondary to burn injury. ⋯ The patient underwent unilateral left hand transplantation with an allograft designed to include a volar forearm fasciocutaneous extension supplied by the radial artery and including the basilic vein to permit augmented venous drainage by means of anastomosis at the antecubital fossa. The volar forearm fasciocutaneous extension can increase vessel caliber and possibly improve reliability in the setting of hand transplantation and should be considered following severe burn injury.