Catheter-Based Donor Site Analgesia After Rib Grafting: A Prospective, Randomized, Double-Blinded Clinical Trial Comparing Ropivacaine and Bupivacaine

Bilateral Costal Cartilage Harvest for Auricle Reconstruction: A New Technique to Prevent Postoperative Thoracic Deformity

HYPOTHESIS

Unilateral costal cartilage harvesting (UCCH) for auricle reconstruction in children tends to cause thoracic deformities. Therefore, our study aimed to develop a novel bilateral costal cartilage harvesting (BCCH) method to prevent and reduce thoracic deformities.

METHODS

Patients with unilateral microtia who underwent either UCCH (n = 50) or BCCH (n = 46) were enrolled in this study. The grafts for the BCCH group were harvested from the 6th costal cartilage of the ipsilateral hemithorax and the 7th and 8th cartilage from the other hemithorax. Computed tomography and physical examination were performed to identify any physical deformities in the chest contours post-surgery. The cosmetic appearance of the thoracic scars post-surgery was evaluated using the Scar Cosmesis Assessment and Rating Scale (SCAR) and Visual Analogue Scales (VAS cosmetic). The numerical rating scale (NRS) was used to quantify the pain in donor sites. The reconstructed ears were assessed during the follow-up period.

RESULT

None of the patients in the BCCH group developed thoracic deformities, while 16 patients within the UCCH group developed mild (n = 12) or severe (n = 4) thoracic deformities (p < 0.001). The SCAR (3.09 vs. 2.92, p = 0.580) and VAS scores (0.96 vs. 0.90, p = 0.813) did not differ significantly between the two groups. For both treatment arms, the NRS scores were highest on the first-day post-surgery and gradually dropped over the 10 days. No significant differences were found in the NRS scores and the aesthetic outcomes of the reconstructed ears between the two groups.

CONCLUSION

The BCCH method effectively reduced the incidence of thoracic deformity at the donor site without increasing postoperative pain and cosmetic concerns for patients. It could be used clinically to improve patient outcomes of costal cartilage grafts.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3572-3580, 2024.

The Efficacy of Intercostal Nerve Block in the Management of Postoperative Pain After Costal Cartilage Harvest for Craniofacial Reconstruction Systematic Review and Meta-analysis

INTRODUCTION

Autologous costal cartilage harvest is a common procedure in craniofacial reconstruction due to its stability, dependability, and diversity. However, such a procedure is associated with severe donor-site pain postoperatively. Therefore, we aim through this study to compare the efficacy of intercostal nerve block in the management of postoperative pain in patients undergoing costal cartilage harvest for craniofacial reconstruction.

METHOD

This systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The study systematically reviewed MEDLINE, Cochrane, and EMBASE databases without time-limitation.

RESULTS

As a result of reviewing the literature, 33 articles were screened by full-text resulting in 14 articles which met our inclusion/exclusion criteria. However, only four high-quality RCT articles were included in the quantitative synthesis (meta-analysis). The findings of this study suggest that there is no significant difference in pain scores between ICNB and control groups at 12, 24, and 48 h postoperatively, both at rest and with coughing. Therefore, both techniques are considered safe and effective.

CONCLUSION

Our results show evidence of favorable outcome of preventive donor-site analgesia with ICNB for harvesting autologous costal cartilage in multiple studies. However, the overall outcomes were insignificant between the two arms.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

Effects of single-injection intercostal nerve block as a component of multimodal analgesia for pediatrics undergoing autologous auricular reconstruction: A double-blinded, prospective, and randomized study

Background

ː Pain management is essential in postoperative settings, especially with pediatric patients. Donor site pain after rib cartilage harvest is severe, particularly during the early postoperative period. This study aimed to explore the effectiveness of ultrasound guided single-injection intercostal nerve block (ICNB) as a component of multimodal analgesia for pediatrics undergoing autologous auricular reconstruction.

Methods

ː Fifty pediatric patients aged 6-16 years and scheduled for 2 rib cartilages harvest surgery were enrolled in this double-blind, prospective and randomized study. Pediatrics were randomly assigned into two groups: the intercostal nerve block group (group B) and the control group (group C). The nerve block was performed with 2 ml 0.25% ropivacaine each intercostal nerve in group B. Patients from group C received Tramadol 2 mg/kg by the end of the surgery as control. Tramadol-based patient-controlled intravenous analgesia and rescue analgesia were given in both groups. The primary outcome was pain scores at early postoperative period (VAS and FLACC scale, 4 h, and 8 h). The secondary outcome was the postoperative Tramadol consumption and time point of first rescue analgesic demand.

Results

ː VAS score was significantly lower in group B than group C at 4 h and 8 h postoperatively [2.5(2-5) vs. 4(2.5-5.5), p = 0.041 at 4 h; 3(2.5-4.5) vs. 4(3-5), p = 0.047 at 8 h]. Total Tramadol consumption in group B decreased significantly in contrast with group C at 8 h (p < 0.01), 12 h, 24 h and 48 h (p < 0.05, respectively). The first rescue analgesia demand and number of rescue Tramadol in block group was considerably delayed or reduced than control group (p < 0.01, p < 0.05, respectively).

Conclusions

ː Our findings indicated that ultrasound guided ICNB slightly but significantly reduced pain scores, and Tramadol consumption in pediatric patients after rib cartilage harvest as compared to who didn't receive nerve block at 4 h and 8 h postoperatively. Unified ICNB ropivacaine dosage might detrimental to providing superior analgesia.

Application of methylene blue combined with ropivacaine intercostal nerve block in postoperative analgesia of autologous costal cartilage augmentation rhinoplasty

OBJECTIVE

To observe the effect of methylene blue combined with ropivacaine intercostal nerve block on postoperative analgesia after autologous costal cartilage augmentation rhinoplasty.

METHODS

In this study 100 female patients who underwent autologous costal cartilage comprehensive augmentation rhinoplasty in Chongqing Huamei Plastic Surgery Hospital from April to November 2021 were randomly divided into an experimental group and a control group, with 50 cases in each group. In the experimental group methylene blue was combined with ropivacaine intercostal nerve block as patient controlled intravenous analgesia (PCIA), and the control group was ropivacaine intercostal nerve block combined with PCIA. The visual analogue scale (VAS) scores of resting and coughing at 6 h (T1), 24 h (T2), 48 h (T3), 72 h (T4) after surgery were recorded and evaluated. At the same time, the number and times of oral analgesics were recorded as well as nausea, vomiting, burning pain and paresthesia.

RESULTS

The VAS scores of the experimental group were lower than those of the control group at all time points. At 6 h, 24 h and 48 h after surgery, the VAS score of the experimental group was lower than that in the control group, but the difference was not statistically significant (P > 0.05). The VAS score of calm 72 h after surgery in the experimental group was significantly lower than that in the control group (P < 0.05). The analgesic effect of the two groups was better when they coughed after surgery. At 6 h after surgery, the VAS score of coughing in the experimental group was lower than that in the control group, but the difference was not statistically significant (P > 0.05); At 24 h, 48 h and 72 h after surgery, the VAS score of the coughing state in the experimental group was significantly lower than that in the control group (P < 0.05).

CONCLUSION

Intercostal nerve block with methylene blue combined with ropivacaine can achieve good postoperative analgesic effects in augmentation rhinoplasty with autologous costal cartilage.

Costal Cartilage Harvest Through a Small Incision in Asian Rhinoplasty After Breast Augmentation

BACKGROUND

The costal cartilage is widely used in rhinoplasty. Although different surgical methods of costal cartilage harvest have been developed, few studies have reported the method of costal cartilage harvest for patients after breast augmentation. This study aims to provide our experience of costal cartilage harvest through a small incision approach.

METHODS

A retrospective review was performed for patients undergoing esthetic rhinoplasty with costal cartilage after breast augmentation between May 2019 and May 2021. Postoperative pain was evaluated with the Visual Analog Scale, and the scars at the donor site were assessed 1 year postoperatively with the Modified Vancouver Scar Scale.

RESULTS

A total of 23 female patients were included. The average follow-up time was 21.4 months. No complications of massive bleeding, pleural injury, or breast implant injury during the surgery, wound dehiscence, or wound infection in the harvested site were observed. No patients complained of changes in breast morphology or breast asymmetry after costal cartilage harvest. Results of Visual Analog Scale for donor-site pain indicated pain in donor-site peaked at 12 hours after surgery and gradually decreased. All patients were satisfied with the scarring of the donor sites after surgery.

CONCLUSION

The better scar performance, low complication rates, and high satisfaction among patients suggest that this is a safe technique to harvest costal cartilage with a small incision in rhinoplasty for patients after breast augmentation.

Ultrasound-guided Bilateral Serratus Anterior Plane Block for Postoperative Analgesia in Ear Reconstruction after Costal Cartilage Harvest: A Randomized Controlled Trial

BACKGROUND

Costal cartilages harvest for ear reconstruction is accompanied by severe pain in chest. However, there is no perfect solution for reducing this chest pain.

OBJECTIVE

Evaluate the efficacy and safety of analgesia using ultrasound-guided bilateral serratus anterior plane block (SAPB) in children receiving costal cartilage harvest for ear reconstruction.

METHODS

Sixty children undergoing ear reconstruction using costal cartilage were randomized to an SAPB group (SAPB with 3 mg/kg 0.25% ropivacaine) or an incision infiltration (II) group (II with 3 mg/kg 0.75% ropivacaine), and 29 in each group completed the study. All children received patient-controlled intravenous analgesia (PCIA). The primary outcomes were numerical rating scale (NRS) scores of pain while rest and coughing at 1, 6, 12, 24, and 48 h after surgery. The secondary outcomes were sufentanil use within 24 h, duration of analgesia, use of oral rescue analgesics, first time out of bed, and incidence of treatment-related adverse effects.

RESULTS

The SAPB group had lower rest and coughing NRS scores at 6 and 12 h after surgery (all P < 0.001), but the scores were similar at other times. The SAPB group used less sufentanil within 24 h, but had a longer duration of analgesia (both P < 0.001). The II group used more oral rescue analgesics within 48 h, had a longer time until first time out of bed, and had more opioid-related side effects (all P < 0.01). There were no SAPB-related complications.

CONCLUSION

Ultrasound-guided SAPB can provide safe and effective regional pain relief after costal cartilage harvest for ear reconstruction.

LEVEL OF EVIDENCE 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 https://www.springer.com/00266 .

A Modified Large-Cap Graft in East Asian Revision Rhinoplasty

BACKGROUND

Reconstructing a well-defined nasal tip is a big challenge for East Asian patients, especially with nasal tip irregularities or short noses in revision rhinoplasty. This study aims to report our experience with a modified large-cap graft for improving the contour of the nasal tip in revision rhinoplasty.

METHODS

A retrospective review was conducted for 91 patients (81 females, 10 males; mean age, 26.8 ± 6.7 years) who underwent revision rhinoplasty with a modified large-cap graft. The rhinoplasty outcome evaluation (ROE) was used for investigating patient satisfaction. The aesthetic outcomes were assessed by preoperative and postoperative photographs by two blinded plastic surgeons using the Independent Rhinoplasty Outcome Score.

RESULTS

Most patients reported satisfactory aesthetic outcomes with overall ROE score increasing from preoperative 11.66 ± 3.98 to postoperative 17.30 ± 5.03 (p < 0.001). The doctors' evaluations on the improved contour of the nose rendered an overall score of 3.77 ± 0.42. The complication rate was 3.3% (pleural tear, 1.1%; hypertrophic scar, 2.2%) at the donor site, and 7.7% at the recipient site (warping, 3.3%; extrusion, 1.1%; deviation, 2.2%; infection, 1.1%). No other complications were observed during follow-up.

CONCLUSIONS

Large-cap graft may be safe and efficient for reconstructing contour of the nasal tip in revision rhinoplasty for East Asian patients.

LEVEL OF EVIDENCE IV

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 .

Comparison of Multimodal Cocktail to Ropivacaine Intercostal Nerve Block for Chest Pain After Costal Cartilage Harvest: A Randomized Controlled Trial

Objective: To compare the effectiveness of an intercostal nerve block after costal cartilage harvest when a multimodal cocktail or ropivacaine plus patient-controlled analgesia is used, as measured by visual analog scale (VAS) scores, rescue analgesic consumption, and related complications. Materials and Methods: Eligible patients who underwent costal cartilage harvest were equally randomized to receive a multimodal cocktail (multimodal group) or ropivacaine plus patient-controlled analgesia (ropivacaine group). Results: Of 112 patients assessed, 12 (10.7%) patients were excluded and 100 (89.3%) patients were enrolled and assigned to multimodal group (n = 50) and ropivacaine group (n = 50). The VAS scores in the multimodal group were significantly lower than those in the ropivacaine group both at rest (0.924 ± 0.073 vs. 1.920 ± 0.073, p < 0.001) and during coughing (2.340 ± 0.083 vs. 3.944 ± 0.083, p < 0.001) in mixed-effects model analysis. Rescue analgesic consumption and rate of complications were significantly lower in the multimodal group compared with the ropivacaine group (all p < 0.05). Conclusions: Multimodal cocktail improved chest pain after costal cartilage harvest with less rescue analgesic consumption and complications compared with ropivacaine plus patient-controlled analgesia. Clinical Trial Registration: ChiCTR2100042445.

Comparison of anaesthetic efficacy of ropivacaine (0.75% & 0.5%) with 2% lignocaine with adrenaline (1:200000) in surgical extraction of bilateral mandibular 3rd molars using IANB:a prospective, randomized, single blind study

Aim

To evaluate and compare the anaesthetic efficacy of 0.75% ropivacaine and 0.5% ropivacaine with 2% lignocaine with 1:200000 Adrenaline (LWA) for surgical extraction of bilateral mandibular 3rd molars using Direct inferior alveolar nerve block (IANB).

Material and methods

Total of 60 outpatients of both sex,age group of 18-40 included in a prospective, randomized, single blind, split mouth clinical study after satisfying inclusion and exclusion criteria. Group I includes 30 patients and 0.75% ropivacaine as test drug, Group II includes 30 patients and 0.5% ropivacaine as test drug. In both group control drug was LWA.Parameters measured were onset of action, duration of action, systolic blood pressure, diastolic blood pressure, heart rate, visual analogue scale (VAS), faces pain scale (FPS).

Result

Onset of action of 0.75%/0.5% ropivacaine (101.84 ​± ​16.92 ​secs/113.03 ​± ​12.77 ​sec) was faster than LWA (Group I-218 ​± ​21.51 ​secs, Group II-196.47 ​± ​26.27 ​secs). Duration of action of 0.75%/0.5% ropivacaine (343.55 ​± ​16.44 ​mins/319.03 ​± ​19.30 ​mins) was longer than 2% Lignocaine with 1:200000 adrenaline (Group I I-173 ​± ​16.86 ​mins, Group II-175.20 ​± ​18.02 ​mins). In Group I - VAS/FPS of 0.75% Ropivacaine (0.97 ​± ​0.54/1.32 ​± ​0.65) was significantly lower as compared to LWA (2.90 ​± ​0.83/3.29 ​± ​0.69). In group II-VAS/FPS of 0.5% ropivacaine (1.40 ​± ​0.72/1.47 ​± ​0.50) was lower as compared to LWA (3.40 ​± ​0.89/3.30 ​± ​0.87). Mean systolic blood pressure, diastolic blood pressure, heart rate was lower for ropivacaine (0.75%, 0.5%) than LWA except mean heart rate higher for 0.75% ropivacaine at 10 ​min after injection. Else mean heart rate lower in other time interval.

Conclusion

Ropivacaine (0.75%,0.5%) was more efficacious than 2% lignocaine with adrenaline (1:200000) it terms of all measured parameters in study.

A Review of Wound Infusion With Local Anesthetics in Plastic Surgery

BACKGROUND

Suboptimal pain management is a common, yet largely unrecognized, problem in the postsurgical patient population. Current treatment protocols heavily rely on opioid use and, though generally effective in providing pain relief, are associated with multiple side effects. The present systematic review aims to offer plastic surgeons insight into the current state of literature on prolonged local anesthetic wound infusion regimens, evaluating both their efficacy in lowering pain scores and the potential opioid-sparing effect.

METHODS

A comprehensive literature search of the Medline, Embase, and Cochrane Library databases was performed to identify relevant studies published between 1980 and December 2017 evaluating the use of prolonged local anesthetic wound infusion for postoperative pain management in plastic surgery.

RESULTS

A total of 28 articles were selected, including 3904 patients. The overall infection rate in all patients treated with postsurgical local anesthetic wound infiltration was 0.28% (7/2536). There were no reported cases of systemic toxicity. An opioid-sparing effect was found in 92% (12/13) of studies when compared to an active comparator and 88% (7/8) of those comparing to placebo. Pain scores were decreased in 90% (9/10) of studies comparing wound infiltration to narcotic-based regimens and in 67% (6/9) of those comparing to placebo.

CONCLUSIONS

Continuous or intermittent wound infusion is safe and effective in reducing pain scores and opioid consumption in plastic surgery. Though the overall pain-lowering effect appears to be modest, ease of catheter insertion and patient satisfaction make this technique an alluring alternative to more validated approaches such as neuraxial or peripheral nerve blocks.

Association of Autologous Costal Cartilage Harvesting Technique With Donor-Site Pain in Patients Undergoing Rhinoplasty

Importance

Postoperative pain at the donor site is a common morbidity following autologous costal cartilage grafting.

Objective

To evaluate postoperative pain at the donor site after the use of a muscle-sparing costal cartilage harvesting technique compared with a muscle-cutting technique using electrocautery.

Design, Setting, and Participants

Designed as a controlled trial without randomization, this prospective, comparative cohort study was conducted between January 1, 2016, and March 31, 2017. Participants included 20 patients who underwent rhinoplasty for various cosmetic and functional complaints from January 1, 2016, to February 28, 2017. Of the 20 patients, 1 was excluded owing to an infection that developed on postoperative day (POD) 7. Patients were grouped by the rib harvesting technique used that was either a muscle-sparing technique (n = 11) or a muscle-cutting technique (n = 8). Skin incisions for both groups were carried out with a blade. Transection of muscle fascia and muscle fibers was performed with monopolar electrocautery in the muscle-cutting technique group. Blunt dissection with a hemostat was performed in the muscle-sparing technique group. All other surgical techniques were identical.

Main Outcomes and Measures

Postoperative pain was assessed with visual analog scale scores for resting pain and movement pain. Eight pain measurements were noted at the sixth postoperative hour and on PODs 1, 2, 3, 7, 15, 30, and 45. During the hospital stay, the postoperative need for analgesics was recorded daily as the number of analgesic infusion vials used.

Results

The 19 patients in the study included 11 women and 8 men whose mean age (SD) was 33.2 (10.3) years The mean (SD) visual pain analog scale scores for resting pain and movement pain were consistently higher in the muscle-cutting technique group than in the muscle-sparing technique group. This difference was statistically significant on PODs 2, 3, and 15 for resting pain and on PODs 2, 3, 7, 15, 30, and 45 for movement pain. The mean postoperative need for analgesic infusion vials during hospital stay was higher in the muscle-cutting technique group, and the difference was statistically significant on POD 2 (1.9 [0.6] vials vs 1.0 [0.9] vials; P = .02).

Conclusions and Relevance

Both resting and movement pain at the donor site was significantly reduced in the muscle-sparing technique group during the postoperative period, findings that align with anecdotal reports in the literature. Routine use of the muscle-sparing technique in autologous costal cartilage harvesting is recommended to reduce postoperative pain.

Level of Evidence

2.

Management of postoperative pain in maxillofacial surgery

In this review we describe the evidence base for postoperative analgesia after maxillofacial surgery. We discuss the implications of poorly managed pain, risk factors for the development of severe pain, and pharmacological and non-pharmacological analgesic strategies to manage it.

Efficacy and safety of 1% ropivacaine for postoperative analgesia after lower third molar surgery: a prospective, randomized, double-blinded clinical study

OBJECTIVES

The purpose of this study was to investigate postoperative analgesic effect of ropivacaine administered as main or supplemental injection for the inferior alveolar nerve block (IANB) in patients undergoing lower third molar surgery.

MATERIALS AND METHODS

The double-blind randomized study comprised 72 healthy patients. All patients received two blocks, the IANB for surgical procedure + IANB after surgery for postoperative pain control, and were divided into three groups: (1) 2 % lidocaine/epinephrine + 1 % ropivacaine, (2) 2 % lidocaine/epinephrine + saline, and (3) 1 % ropivacaine + saline. The occurrence of postoperative pain, pain intensity and analgesic requirements were recorded. Data were statistically analyzed using chi-square, Fisher, and Kruskal-Wallis tests and analysis of variance (ANOVA) with Bonferroni and Tukey correction.

RESULTS

Ropivacaine was more successful than lidocaine/epinephrine in obtaining duration of postoperative analgesia, reduction of pain, and analgesic requirements whether ropivacaine was used for surgical block or administered as a supplemental injection after surgery.

CONCLUSIONS

Ropivacaine (1 %, 2 ml) resulted in effective postoperative analgesia after lower third molar surgery.

CLINICAL RELEVANCE

Since pain control related to third molar surgery requires the effective surgical anesthesia and postoperative analgesia, the use of 1 % ropivacaine could be clinically relevant in a selection of appropriate pain control regimen for both surgical procedure and early postsurgical treatment.

Continuous postoperative pain control using a multiple-hole catheter after iliac bone grafting: comparison between ropivacaine and levobupivacaine

The aim of this study was to compare the analgesic effects of ropivacaine and levobupivacaine in continuous infiltration anaesthesia delivered via a multiple-hole catheter for the purpose of postoperative analgesia after iliac bone grafting. Thirty-four patients scheduled for iliac bone grafting in the maxillofacial region participated in this study. The patients were randomized to a ropivacaine group (Ropi group) and a levobupivacaine group (Levo group). After harvesting the iliac bone for grafting, a multiple-hole catheter was placed on the periosteum of the iliac bone. When surgery was completed, continuous administration was started at 4 ml/h of 0.2% ropivacaine (Ropi group) or 0.25% levobupivacaine (Levo group). Pain was evaluated in the recovery room and at 4h after surgery, as well as at 9:00 and 18:00 on postoperative days 1, 2, and 3, using a visual analogue scale. Side effects were also recorded. No significant difference in the visual analogue scale scores at rest or in motion was observed between the two groups. In addition, there were no side effects in the two groups. Both 0.2% ropivacaine and 0.25% levobupivacaine provided comparable analgesic effects in continuous infiltration anaesthesia delivered via a multiple-hole catheter after iliac bone grafting.

Fever after maxillofacial surgery: a critical review

PURPOSE

The aim of this paper is to review the pathophysiology of thermoregulation mechanism, various causes of fever after maxillofacial surgery and the different treatment protocols advised in the literature.

DISCUSSION

Fever is one of the most common complaints after major surgery and is also considered to be an important clinical sign which indicates developing pathology that may go unnoticed by the clinician during post operative period. Several factors are responsible for fever after the maxillofacial surgery, inflammation and infection being the commonest. However, other rare causes such as drug allergy, dehydration, malignancy and endocrinological disorders, etc. should be ruled out prior to any definite diagnosis and initiate the treatment. Proper history and clinical examination is an essential tool to predict the causative factors for fever. Common cooling methods like tepid sponging are usually effective alone or in conjunction with analgesics to reduce the temperature.

CONCLUSION

Fever is a common postoperative complaint and should not be underestimated as it may indicate a more serious underlying pathology. A specific guideline towards the management of such patients is necessary in every hospital setting to ensure optimal care towards the patients during post operative period.