[Birth of rhinoplasty in the West]

The birth of rhinoplasty in the West was driven by a great demand for reconstruction of noses destroyed voluntarily or not, post-traumatic or medical. Two men emerge strongly through their work and writings: Gaspare Tagliacozzi for the brachial flap and Joseph Carpue for the frontal flap. Both of them describe a different method but based on the same skin flap principles. But were they really the first? History tells us that other, more anonymous people before them had used these same methods on a large scale but without leaving any conclusive or very significant written trace. The use of flaps or grafts, methods, which are the true pillars of plastic surgery, opened up perspectives much wider than the nose. But history has retained the name of these two men through their writings. If they were not the precursors, they were nevertheless promoters, laying the foundations of modern plastic surgery and promoting the spread of these great principles throughout the world.

The role of interscalene brachial plexus block anaesthesia in arthroscopic shoulder surgery; a prospective study

The choice of anaesthetic in shoulder surgery is an evolving field of research which has important implications for patient outcomes. We have performed a prospective study to assess the usability of an interscalene brachial plexus block (ISBPB) with sedation as the primary anaesthetic and analgesic for arthroscopic shoulder surgery. Our study assessed the requirements of analgesia peri-operatively and post operatively and found that patients had no requirement (n = 30) and minimal requirements with a low pain score (visual analogue score; mean 2.4, range 2-5) respectively. We also found that patients spent a short amount of time in recovery (31 min mean, range 21-48 min) and were able to be discharged on the same day. Our findings suggest that ISBPB with sedation is a viable option in arthroscopic shoulder surgery for a variety of procedures with positive effects for patient outcomes and mobility.

EPIDEMIOLOGICAL STUDY OF TRAUMATIC BRACHIAL PLEXUS INJURIES

OBJECTIVE

To conduct an epidemiological study on brachial plexus injuries, through data collection of patients treated in the Hospital São Paulo, which is the referral center for high complexity in this region.

METHODS

We conducted a retrospective study with a review of the electronic medical records of the Hospital, from August 2008 to June 2013.

RESULTS

We estimated an 1.88/100,000 annual incidence, considering that the Hospital is the only referral center for brachial plexus injuries. The mean time between injury and the first visit to the reference hospital was 8.25 months. The mean time interval between injury and surgery was 11.25 months. The percentage of total injuries was 33%, while the upper and middle trunk injuries were 33% and 28%, respectively.

CONCLUSION

We observed many aspects in common with those reported by other centers of excellence in Brazil such as: sex, age and mechanism of injury. However, some findings were different from most other epidemiological studies, namely: level of injury, time between the accident and the first appointment and the time between injury and surgery. Level of evidence IV, case series.

Effect of oral L-citrulline on brachial and aortic blood pressure defined by resting status: evidence from randomized controlled trials

Background

Experimental evidence indicates that oral L-citrulline (L-Cit) may reduce resting blood pressure (BP) as well as BP responses to exercise and cold exposure (non-resting). However, results from human intervention trials are inconsistent. This study aims to summarize the clinical evidence regarding the effects of L-Cit supplementation on brachial systolic blood pressure (SBP), brachial diastolic blood pressure (DBP), in addition to aortic SBP and aortic DBP at rest and non-resting conditions.

Methods

Multiple databases including PubMed, Embase, Cochrane library, Web of Science, and Clinical Trials were searched systematically. Randomized controlled trials of human participants were quantitatively meta-analyzed.

Results

Fourteen trials contained in eight studies were available for quantitative syntheses for brachial BP. Results showed that L-Cit supplementation significantly reduced both brachial SBP (− 4.490 mmHg, 95% CI: − 7.332 to − 1.648, P = 0.002) and brachial DBP (− 3.629 mmHg, 95% CI: − 5.825 to − 1.434, P = 0.001). Nine of the trials were meta-analyzed for aortic BP which showed that L-Cit intervention significantly reduced aortic SBP (− 6.763 mmHg, 95% CI: − 10.991 to − 2.534, P = 0.002), but not aortic DBP (− 3.396 mmHg, 95% CI: − 7.418 to 0.627, P = 0.098). The observed reducing effects of L-Cit appeared stronger for non-resting than for resting brachial SBP (P for difference = 0.044).

Conclusion

L-Cit supplementation significantly decreased non-resting brachial and aortic SBP. Brachial DBP was significantly lowered by L-Cit regardless of resting status. Given the relatively small number of available trials in the stratified analyses and the potential limitations of these trials, the present findings should be interpreted cautiously and need to be confirmed in future well-designed trials with a larger sample size.

Avoidance of scapular winging while approaching tumors of the middle scalene region

BACKGROUND

Large tumors arising from the middle scalene region can displace the middle scalene muscle and distort regional anatomy, placing nerves at risk. Understanding the surgical anatomy of these nerves is key to approaching pathology of the middle scalene muscle and avoiding damage to the dorsal scapular, long thoracic, and spinal accessory nerves, each of which can cause scapular winging and associated morbidity if injured.

METHODS

IRB approval was obtained for this study, allowing cases with relevant pathology to be reviewed and presented to highlight the relevant surgical technique. Anatomical depictions were created to correlate intraoperative images with known anatomical relationships.

RESULTS

Key to this approach is consideration of the regional anatomy in a standard supraclavicular approach, the superficial plane, containing the anterior scalene muscle and brachial plexus, and the oblique plane containing the middle scalene muscle, long thoracic, spinal accessory, and dorsal scapular nerves. Identification and mobilization of each of these structures prior to lesion removal can not only provide likely boundaries of the tumor, but also allow for protection of the nerves to avoid injury that may lead to scapular winging with associated morbidity and functional impairment of the upper extremity.

CONCLUSIONS

Lesions of the middle scalene region often split two important anatomical planes, the superficial and deep, creating an advantageous surgical corridor through an anterolateral approach. Through early identification of known anatomy, these two planes can be developed, and a safe approach to the lesion of the middle scalene region can be exploited.

Intraoperative Angiography for Arteriovenous Malformation Resection in the Prone and Lateral Positions, Using Upper Extremity Arterial Access

BACKGROUND

Intraoperative angiography is routinely utilized for aneurysms and arteriovenous malformations (AVMs) to verify complete occlusion and resection. Surgery for spinal and posterior fossa neurovascular lesions is usually performed in prone position. Intraoperative angiography in the prone position is challenging and there is no standardized protocol for this procedure.

OBJECTIVE

To describe our experience with intraoperative angiography in the prone and lateral positions, using upper extremity arterial access.

METHODS

We reviewed our experience with intraoperative angiography in the prone position between 2014 and 2015, where vascular access was obtained via the upper extremity arteries. Patients were treated in a hybrid endovascular operating room. High cervical and intracranial lesions were studied via brachial or radial access. All accesses were obtained using ultrasonographic guidance and a small caliber arterial sheath (4F).

RESULTS

Five patients were treated in the prone and lateral positions using brachial/radial artery access. Patients harbored cerebellar AVM, lateral medullary AVM, cervical arteriovenous fistula (AVF), tentorial dural AVF, and tentorial-incisural dural AVF. Patients were positioned prone (n = 2), semiprone (n = 2), and lateral (n = 1) for the surgery. Three patients were treated via right brachial artery access. Two patients were treated via radial arteries access. All patients tolerated the procedures without technical or clinical complications. Intraoperative angiography verified complete occlusion and resection in all cases prior to surgical closure.

CONCLUSIONS

Intraoperative angiography in the prone and lateral positions using upper extremity access is an important adjunct. Brachial or radial access can be obtained safely and provides comfortable and quick approaches.

Unusual branching pattern of brachial artery - Embryological basis and clinicoanatomical insight

Variations in the arterial pattern of upper limb are of colossal importance to the surgeons as they are liable to iatrogenic injuries. During routine dissection for undergraduate medical students, an anomaly of brachial artery was discovered. The brachial artery terminated at higher level into ulnar and radial artery. The common interosseus artery took origin arising from radial artery. The ulnar artery did not give any branches in the forearm. Both radial and ulnar artery displayed a superficial course in the forearm. The anatomical knowledge of these variations may be of great help for the clinicians in planning and conducting flap harvesting during reconstructive surgeries and in arteriography.

Sources of variation in plasma corticosterone and dehydroepiandrosterone in the male northern cardinal (Cardinalis cardinalis): II. Effects of urbanization, food supplementation and social stress

Perturbations in an organism's environment can induce significant shifts in hormone secretory patterns. In this context, the glucocorticoid (GC) steroids secreted by the adrenal cortex have received much attention from ecologists and behaviorists due to their role in the vertebrate stress response. Adrenal GCs, such as corticosterone (CORT), are highly responsive to instability in environmental and social conditions. However, little is understood about how adrenal dehydroepiandrosterone (DHEA) is influenced by changing conditions. We conducted field experiments to determine how circulating CORT and DHEA vary during restraint stress in the male northern cardinals (Cardinalis cardinalis). Specifically, we examined how four different changes in the physical (urbanization and food availability) and social (territorial conflict, distress of a mate) environment affect CORT and DHEA levels. The majority of cardinals responded to restraint stress by increasing and decreasing CORT and DHEA, respectively, however this depended on sampling context. Cardinals sampled from urban habitats had both lower initial and restraint stress CORT concentrations, but a comparable DHEA pattern to those sampled from a forest. Supplementing food to territorial males did not alter circulating initial DHEA or CORT concentrations nor did it change the response to restraint stress when compared to unsupplemented controls. Exposing cardinals to varying durations of song playback, which mimics a territorial intrusion, did not affect CORT levels, but did attenuate the DHEA response to restraint stress. Examining a larger dataset of males captured before, after or at the same time as their female mate, allowed us to address how the stress of a captured mate affected the male's CORT and DHEA response. Males showed elevated initial and restraint CORT and DHEA when their female mate was captured first. Taken together, these data demonstrate that both CORT and DHEA secretion patterns depends on environmental, and particularly current social conditions.