Plastic Reconstructive & Aesthetic Surgery

Lotte Hardman has completed her MBChB from University of Liverpool in 2013 and her MSc in Humanitarian Studies from Liverpool School of Tropical Medicine 2012. She has published papers in humanitarian, bioscience and surgical topics and is developing her interest in Plastic Surgery in the North West of England.

Introduction:Free flap monitoring without prompt intervention can result in partial or total flap loss. Monitoring devices including implantable dopplers, thermal imaging and oxygen saturation monitoring have been introduced, but none of them has been fully validated or implemented as a gold standard. The FLO scoring chart was designed as an easy monitoring tool with a trigger mechanism to prompt early review. The concept is to create a universal score for flap health that would be an extension to MEWS score.\r\nMethodology: The new free flap scoring chart was introduced in our unit in Sep’2018. It consists of four flap variables; temperature, colour, capillary refill time, doppler signal and three physiology parameters related to hydration status and hence flap health; heart rate, blood pressure and urine output. The aim was to evaluate the effectiveness of the new system as a sensitive monitoring tool and outcome predictor.rnrnResults: From Sep’ 2018 to Nov’ 2018, 43 free flap cases were included. Flap loss was 4.6% with an average time to intervention for failing flaps of 3.5hrs. In comparison to the preceding six-month period; there were 85 free flaps with 11.2% failure rate and an average time to intervention of 5.9 hrs. The score system was found to be an improvement of the previous chart by the nursing staff and was universally accepted after implementation. Conclusion: The implementation of the FLO scoring system was found to be an improvement on free flap survival and a reduced time to intervention. It was proven to be a user-friendly monitoring tool with an integrated escalation sequence to prompt earlier intervention, which promotes safer surgery. The authors recommend further validation of the FLO scoring system and development into an e-FLO score.

Reuben I Thaker, MD, JD, MPH, practices cosmetic surgery and wellness medicine, in private practice, Las Vegas, Nevada. His practice focuses on minimally invasive techniques to optimize cosmetic outcomes, and minimize risks associated with anesthesia and prolonged recovery times. In addition to multiple clinical board certifications, he completed a National Institute of Health Fellowship, with a research focus on wound healing and immunological properties of the dermis.

Background: Hair transplantation is performed in the office setting with locally injected anesthetic, nearly exclusively. Lidocaine is injected alone or combined with longer-acting amide anesthetics, epinephrine, or other agents. Safe maximum doses of lidocaine are based on patient weight. 4.5 mg/kg lidocaine, or 7 mg/kg lidocaine with epinephrine, is an often cited maximum local dose. However, cardiac, nervous system, and other adverse effects can occur unpredictably. Unique feature of hair transplantation may also warrant vigilance for toxicity at lower doses. \r\n\r\nCase presentation: 45 yr male underwent 972 follicular unit extraction (FUE) grafts for androgenic alopecia, in 6.6 hours over two days. 90 ml total of local anesthetic solution was injected [60% Lidocaine 0.5% + 40% Marcaine 0.25%, w/epinephrine 1/200,000], with dicloxacillin and dexamethasone oral, midazolam 35 mg intramuscular. Chest pain and vomiting hours after surgery prompted emergency room visit and overnight hospital observation. During hospitalization, new onset atrial fibrillation was diagnosed, also dehydration. Intravenous and oral diltiazem resolved all symptoms and arrhythmia. Cardiology prescribed oral diltiazem, discontinued anticoagulation, advising routine follow up.\r\n\r\nDiscussion: Local anesthesia for FUE hair transplantation may more accurately resemble a combination of local injection, nerve block, and tumescent anesthesia, versus local injections in other body areas. Published dosing standards should be followed for local anesthetics including lidocaine, though monitoring for toxicity is warranted regardless of dose. Prolonged scalp injections may not follow pharmacokinetics of dissimilar tissues nor for tumescent lidocaine, and a different standard may need to be developed. Multiple agents in anesthetic solution, and medications such as for sedation, can promote adverse effects. Medications may compete with lidocaine for cytochrome P450 metabolism, such as benzodiazepine administered here. Further, prolonged use of high dilution local anesthetics, in a highly vascular tissue with minimal adiposity, may be unique to hair transplantation. Hair transplantation thus warrants further study as to safe local anesthetic dosing strategies.