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A substantial volume of a plastic surgeon's workload involves surgery on the digits, ears and nose otherwise known as ‘end-artery systems’. The inclusion of adrenaline to anaesthetise such systems has long been recognised as malpractice due to the possibility of inducing necrosis. The objective of this study was to demonstrate that reports claiming adrenaline induces necrosis in ‘end-artery systems’ are false and that evidence exists proving its safety in local anaesthesia.
A retrospective review of the literature was performed analysing reports proving the safety of adrenaline in end-organ anaesthesia over the past 40 years.
Twenty-one pre-1950 cases are responsible for creating this dogma. They all involved the use of procaine, for which reports exist of mixtures having expired and demonstrating a pH as low as 1. Randomised controlled trials and a number of large series utilising Doppler analysis of arteries have been published supporting the use of adrenaline.
It is clear that the dogma regarding adrenaline has been founded on a lack of evidence. When used correctly, adrenaline can reduce bleeding, negating the need for a tourniquet and can lengthen the duration of anaesthesia of plain lignocaine. These findings are significant to plastic surgeons and those in emergency medicine.
‘Smile Surgery’ for facial paralysis involves re-creating both the correct nasolabial fold and smile pattern in order to improve aesthetic and functional outcomes. Both static and dynamic procedures involve placement of a scar within the crease. No previous study has classified the nasolabial fold whose shape and depth varies between individuals. The ability to classify current or future fold pattern gives guidance to scar placement which in turn affects procedural choice.
A total of 110 random patients with no facial asymmetry had pictures taken by two trained photographers. Three standard photographs were taken – lips at rest, smile with lips closed, and smile showing teeth. Results were analysed and then verified by an independent observer.
The photographs suggested the following classification:
|Type 1||No nasolabial fold|
|Type 2||Fold just near nasal alar region only|
|Type 3||Fold around corner of mouth only|
|Type 4a||Fold from nose to corner of mouth|
|Type 4b||Bifid/complex fold, from nose to corner of mouth with extension|
We have developed the first, simple, clinically relevant classification of the nasolabial fold.
The aim of this study was to audit the time to instillation of mitomycin-C following transurethral resection of bladder tumours (TURBT) and assess if using the Mito-In® device improved instillation times. Following initial TURBT, patients should receive a dose of intravesical chemotherapy within 24 h (EAU Guidelines), and ideally within 6 h (BAUS). This significantly reduces the risk of recurrence.
Retrospective data collection from 100 case notes where patients had received intravesical mitomycin-C following TURBT. The times to administration were collated along with demographic information, tumour stage and grade. These were compared with times achieved prior to the use of Mito-In®.
|Audit||Pre Mito-In®||Using Mito-In®|
|Mean instillation time||35 h 54 min (range, 6.5–94.5 h)||4 h 9 m (range, 33 min to 25.5 h)|
Ninety-five patients received mitomycin-C postoperatively using the Mito-In® device. The average time to instillation using Mito-In® was 4 h 9 min. There was no evidence of extravasation and treatment was well tolerated.
Mean time to instillation is reduced from over 35 h to 4 h 9 min with use of the Mito-In® device. Overall, 98% of patients received intravesical mitomycin-C within 24 h of TURBT and 84% within the tighter guideline of 6 h.