Treatment of hand deformities in epidermolysis bullosa patients represents a challenging field in hand surgery practice, thus a systematic approach by a team is mandatory for a successful result. A simple and practical algorithm for the surgical treatment of hand deformities in EB was employed by the authors where the deformities of each digit in EB patients was categorized according to pseudosyndactyly and interphalangeal joint contracture severity for guidance during the surgical treatment. The current study retrospectively reviewed the medical records and photographic data of 13 EB patients followed in our department, for whom a systematic approach to the management and treatment was used. Mild cases were treated by surgical release and secondary healing with non-adhesive dressing while moderate cases were treated with autologous dermal grafts harvested with a special technique that were fixed on denuded areas on the proximal interphalageal joints after release. The remaining areas were treated similarly to the mild group. Additional K-wires were applied for two weeks in severe cases. A total of 21 procedures were performed on 13 EB patients with hand deformities according to the proposed treatment strategy. Functional recovery was satisfactory for each patient and the outcomes were dependent upon the severity of deformity. A multidisciplinary and conscious approach followed by an algorithmic surgical treatment protocol described in the study has been beneficial in providing consistent and successful long-term results for these patients.

Surgery is accepted as one of the most demanding professions that create both physical and mental strain on the performers. Therefore, the authors aimed to elucidate the mental burden of surgeons, which is dedicated to operative stress. They also tested the hypotheses that participating in surgery creates mental stress on surgeons that leads to cardiovascular changes, and that this stress is more pronounced for actual operators than for first assistants. The method chosen for this purpose was an analysis of heart rate variability. Twelve surgeons (five plastic surgery staff and seven plastic surgery residents) were monitored by a digital ambulatory Holter recorder on at least two occasions. Half of the recordings were carried out on operating days and the other half on office days. Heart rate variability indices (low frequency, high frequency, high frequency/low frequency ratio, and heart rate) were analyzed from those recordings using computerized research tool software. The heart rate variability indices of the operators showed statistically significant differences between operating days and office hours in favor of an increased sympathetic and decreased parasympathetic activity for the former. For first assistants, three of the parameters, with the exception of heart rate, changed in favor of a sympathetic predominance over parasympathetic activity; these changes were also statistically significant. These results showed a sympathetic hyperactivity for both operators and first assistants during the operations. When the sympathovagal balance of the actual operators was compared with that of assistants, the former group showed a more pronounced sympathetic arousal. This difference is accepted as a proof for the mental stress of the surgery being the main factor responsible for the sympathetic hyperactivity that we detected during the operations. Surgeons continuously face a unique mental strain that other professions rarely bring forth, and these psychological stressors are associated with alterations in cardiac autonomic control that may contribute to the development of cardiac disease. Prolonged sympathetic hyperactivity could anticipate cardiac discomfort in more experienced surgeons with marginal cardiac reserve. Such cardiac diseases would be reconsidered as occupation-related illnesses, which might be reimbursed to the physician. In addition, the legal responsibility of surgeons concerning their unfavorable results might be assessed with more understanding with a realization of their undue working conditions.

Three methods of nerve repair involving the epineural sleeve technique were compared with conventional nerve repair using the rat sciatic nerve transection model in four groups. In group 1, the sciatic nerve was repaired using the conventional epineural technique by placing four sutures. In groups 2, 3, and 4, the epineural sleeve technique was combined with two sutures, fibrin glue, and two sutures with fibrin glue, respectively. Functional recovery was evaluated using walking track analysis, limb circumference, and the severity of toe contracture. Diameter of the sciatic nerve fibers, total number of myelinated fibers, diameter of the myelin sheath, and the axon-to-fiber diameter ratio were measured at 12 weeks. The results showed better functional recovery as well as a higher number of myelinated fibers in groups using the epineural sleeve technique compared with conventional technique ( < 0.05). The addition of fibrin glue, however, did not make any significant difference. The epineural sleeve technique was found to be superior when compared with conventional nerve repair, providing faster functional recovery and improved nerve regeneration.

Neuronal supply in soft tissues may be an important part of cutaneous wound healing. In order to observe the effect of denervation on wound contraction, rectangular full-thickness skin defects were created on the dorsum of two groups of Wistar rats. In the experimental group (n = 20), spinal nerves corresponding to the area of the open wound (T11 to L2) were isolated and divided bilaterally. In the control group (n = 20), the same pairs of spinal nerves were dissected but left intact. Limits of denervation were verified by the pinprick test. Wound healing, which is primarily in the form of wound contraction in this model, was evaluated by tracing wound margins onto millimetric paper weekly. Wound contraction was delayed significantly in the experimental group (p < 0.05) at all follow-up periods when compared with the controls. Loss of neuropeptide secretion from the nerve endings in denervated tissues may be responsible for the retarded wound contraction, since neuropeptides are thought to exert trophic effects on skin wound healing.

This study was conducted to evaluate the effect of epineural sleeve neurorrhaphy on peripheral nerve regeneration. A total of 12 Lewis rats were divided in two groups of 6 rats each. In group 1, the rat sciatic nerve was transected and repaired using the conventional epineural technique with four sutures. In group 2, the epineural sleeve technique was introduced with two sutures only. Functional recovery was evaluated at 1, 2, 4, 8, and 12 weeks by walking track analysis (sciatic function index [SFI]), mean limb circumference ratio, and severity of toe contracture. Although the SFI at 12 weeks revealed no difference between the two groups (+/-88.39 +/- 10.75 conventional group, +/-77.35 +/- 17.06 epineural sleeve group), significant differences in SFIs were detected at 4 and 8 weeks, with better functional recovery in group 2 rats (4 weeks: 125.92 +/- 22.73 conventional group, +/-99.17 +/- 5.45 epineural sleeve group; 8 weeks: +/-96.65 +/- 4.73 conventional group, +/-72.82 +/- 17.11 epineural group; p < 0.05 for both time points). Mean limb circumference ratio was not significant at all time points. At 12 weeks, all animals in the conventional nerve repair group developed severe toe contractures whereas only 2 animals in epineural sleeve repair group had contracture (p < 0.05). In this study, the epineural sleeve technique demonstrated a faster functional recovery when compared with the conventional technique, as confirmed by SFI and toe contracture grading.

Lymphangioma circumscriptum of the penis and scrotum is an unusual entity that may be indistinguishable from genital warts. After confirmation of the diagnosis, a treatment plan consisting of wide excision should be outlined. To lower the chance of recurrence, not only the affected skin but all the subjacent subcutaneous tissue, including the deeper components of the lymphatic malformation just above the deep fascia, should be removed.

No abstract

Thoracodorsal artery perforator (TDAP) flap is a relatively new member of the perforator flap family. The objective of this study is to describe the use of pedicled and free TDAP flaps for various soft tissue defects. Fifteen patients underwent soft tissue reconstruction using 16 TDAP flaps. Twelve pedicled flaps were used for axillary, breast, and shoulder regions. Four free flaps were used for cheek, popliteal, hand, and foot reconstruction. The flaps were harvested based on the perforators, which were preoperatively located at or close to a point 8 cm below the posterior axillary fold and 2 cm behind the lateral border of the latissimus dorsi muscle. Early, late, major, and minor complications were documented. In 13 of the 16 flaps, perforators from the thoracodorsal artery were found in the circle 3 cm in diameter, centered on the anatomic landmark. Three other perforators were found outside this circle. One flap loss was considered the only major complication. Minor complications occurred in 12.5% of flaps. Although the vascular anatomy can be variable, free and pedicled TDAP flap is a versatile option in soft tissue reconstruction.