Notalgia paraesthetica: A pilot study of treatment with simple exercises and stretches.

Notalgia paraesthetica is a distressing condition for which current treatments are either poorly effective or have unacceptable adverse effects. The aim of this pilot study was to evaluate the effectiveness of a programme of simple exercises and stretches for this condition. In total, 12 patients participated in a trial of simple exercises and stretches over 12 weeks, designed to relieve the sensory neuropathy caused by paraspinal muscle entrapment. Of the 12 patients 11 achieved satisfactory amelioration of their symptoms with no adverse effects. Our pilot study was unblinded and consisted of small patient numbers. Further research to evaluate this approach is warranted.

The cervico-submental keystone island flap for locoregional head and neck reconstruction.

BACKGROUND: Locally advanced head and neck cancer often requires wide resections of the cheek and parotid gland, and in an ageing population preferred reconstructive options aim to avoid lengthy operating times or high risk surgery. While most large parotid defects traditionally require free flap reconstruction, we describe a new and versatile locoregional flap that has been shown to be reliable, simple and safe. METHODS: We describe the cervico-submental (CSM) keystone-design perforator island flap for head and neck reconstruction, including an analysis of 33 consecutive patients with a range of head and neck defects. The flap was raised based on perforators of the external carotid artery and its branches, and designed to overlay the C2/C3 dermatomes (an aide memoire for flap design). The indications, and surgical technique are described. RESULTS: In 33 consecutive patients, no major complications were encountered. Five patients developed superficial infections, one developed post-operative bleeding and one patient developed partial tip necrosis. Theatre time was considerably shorter than our alternative reconstructive options. CONCLUSION: The CSM keystone-design perforator island flap is a novel and versatile flap, which can be used in a range of advanced cheek and parotidectomy defects, and may enable improved surgical management in an increasingly elderly and high-risk population.

Vulvar psoriasis in adults and children: a clinical audit of 194 cases and review of the literature.

OBJECTIVE: There are limited data on psoriasis as it affects the vulva in the medical literature. This observational study aimed to describe the symptoms, signs, and management of vulvar psoriasis in adults and children in a private vulvar disease referral practice. MATERIALS AND METHODS: A review of the existing literature on vulvar psoriasis was used to generate inclusion criteria of a chronic noninfective erythematous vulvitis without vaginal involvement. Between January 2009 and October 2011, 201 patients presenting with these criteria were coded as having psoriasis in a computerized database where standardized data were collected. In 194 of these patients, adequate data were available to include in the study. RESULTS: Only 12.3% of the patients presented with psoriasis as a provisional diagnosis with a mean symptom duration of 4.5 years (range = 6 weeks to 35 years). The most common presentation was a pruritic, bilaterally symmetrical, erythematous, nonscaly, well-demarcated macular eruption or slightly raised plaque (82.5%). Of the remaining patients, 9.2% presented with only diffuse symptomatic erythema, whereas 8.2% were symptomatic without erythema. In 64.9% of the patients, evidence of psoriasis was found on other parts of the skin. Initial induction treatment with potent topical corticosteroid followed by a maintenance treatment with less potent topical steroids and other psoriasis-specific treatment such as tar creams and calcipotriol resulted in a suppression of disease in 93.8% of the patients during a mean follow-up duration of 8.9 months (range = 1 month to 7.25 years). CONCLUSIONS: Vulvar psoriasis is a difficult diagnosis that should be considered in patients presenting with a chronic erythematous vulvitis without vaginitis. It is a chronic relapsing skin condition that requires long-term management.

Oncologic clearance with preservation of reconstructive options: literature review and the 'delayed reconstruction after pathology evaluation (DRAPE)' technique.

Intraoperative frozen section and Mohs' micrographic surgery (MMS) are two techniques used to ensure oncological clearance without resorting to unnecessarily wide margins that might compromise reconstructive options for definitive wound closure. In addition to some technical issues, these techniques are suboptimal for resection of tumours such as melanoma, where specific tissue margins at histopathology are required to ensure minimal risk of local recurrence. We describe a technique that minimizes the amount of tissue excised and uses definitive paraffin sections interpreted in a pathology laboratory in order to delay reconstruction until after clear oncologic margins are obtained. This 'delayed reconstruction after pathology evaluation (DRAPE)' technique is particularly directed at extensive and complicated skin lesions, located in areas of the body that can be difficult to reconstruct and are prone to disfigurement and/or loss of function. A review of the literature is undertaken, establishing the role of each technique in achieving clear surgical margins. A case example is presented, highlighting the role of the DRAPE approach. The DRAPE technique is presented as a useful option for high-risk lesions, especially within aesthetically sensitive regions or for complex reconstructions, and when reconstruction can be reasonably delayed while tumour clearance is established.

Autologous dermal grafts for rectus sheath reconstruction and application in closure of ventral myofascial defects.

Ventral abdominal hernias pose a reconstructive challenge, with recurrence rates after primary closure exceeding 50 % and synthetic options at high risk for infection. We describe our experience with using autologous dermis, sourced from the redundant overlying abdominal skin, for reconstruction of ventral abdominal wall defects. We describe the surgical technique, applied anatomy and an analysis of short- and long-term outcomes. Twelve consecutive patients undergoing repair of medium-large size, reducible abdominal wall defects were recruited. The dermal graft technique was used in each case, utilizing an autologous running strip of abdominal skin for reconstruction. Both short- and long-term outcomes were assessed prospectively. Scores were given on a scale of 1-10, with 1 = least/worst and 10 = most/best. The described technique was successfully undertaken in all patients. Long-term follow-up demonstrated a 100 % resumption of normal activities, with an improvement in quality of life and physical activity scores postoperatively, and no recurrences. Short-term complications were notable, with five patients requiring postoperative intensive care unit admission, and seven patients requiring respiratory support. In conclusion, the use of autologous rectus sheath reinforcement may achieve good surgical outcomes and high patient satisfaction. While early respiratory complications should be noted, the potential utility of this technique is worthy of future investigation.

A comparative study of childhood psoriasis and atopic dermatitis and greater understanding of the overlapping condition, psoriasis-dermatitis.

BACKGROUND AND OBJECTIVES: Psoriasis (Pso) in children may be confused clinically with atopic dermatitis (AD) and, indeed, the two conditions may co-exist. The aim of this study was to determine historical and clinical features that are different in paediatric Pso and AD and to describe children who have features of both: psoriasis-dermatitis overlap (PD). METHODS: Children with features of psoriasis or eczema, or both, who were referred to paediatric outpatients and/or private rooms were evaluated. Data were collected from 170 consecutive children aged less than 12 years between July 2011 and November 2011. Participants were classified by described criteria as having Pso (n = 64), AD (n = 62) or PD (n = 44). RESULTS: Only 9.4% of children with Pso were correctly diagnosed by the referring doctor. Children with Pso relative to AD were more likely to have had a history of scaly scalp and nappy rash in infancy, a family history of psoriasis, current scalp and periauricular rashes, defined, patchy plaque morphology and papulosquamous rashes not typical of adult psoriasis on extensor elbows and knees. Children with PD had features of both but presented most often as typical paediatric psoriasis combined with flexural eczema. Children with Pso and PD responded well to specific treatment strategies for psoriasis, including potent topical corticosteroids (TCS), calcipotriol and phototherapy. Both Pso and PD tended to require more potent TCS than AD to achieve disease suppression. CONCLUSION: We found that Pso and PD in children both differ clinically from AD and have identified historical and clinical features that characterise childhood Pso.

Determining between chyle leak and anastomotic leak after esophageal reconstruction: the utility of methylene blue dye.

OBJECTIVES/HYPOTHESIS: Two common complications of esophagectomy and immediate reconstruction comprise thoracic duct injury leading to chyle leak and anastomotic leakage. These can delay optimized nutrition, speech, and swallowing rehabilitation, and thus are important to identify and treat accordingly. When either chyle leak or anastomotic leak are clinically suspected, differentiation between the two can be very difficult clinically. As both complications may result in an increase in drain output once oral intake has occurred, an effective, quick, and accurate tool is required to determine whether this increase in drain output is related to an anastomotic leak or with a increase activity in chyle production. STUDY DESIGN: Retrospective descriptive study. METHODS: Description of the use of oral methylene blue dye as a safe, simple, and quick clinical bedside test. RESULTS: When ingested orally, an anastomotic leak will lead to blue dye staining the neck drain output immediately (within seconds to minutes). A chyle leak may also result in blue staining of the drain output; however, this is not an immediate phenomenon, and rather, based on the bioavailability of methylene blue this would take a minimum of 1 hour, and more likely up to 4 hours, as the dye is absorbed into mesenteric lymphatics and travels via the thoracic duct. CONCLUSIONS: With no documented contraindications or side effects from its oral use (in the absence of hypersensitivity reactions), methylene blue is an inexpensive and freely available test in the postoperative setting of esophageal reconstruction.

A unique deep inferior epigastric artery perforator and implications for a muscle and fascia sparing vertical rectus abdominis myocutaneous flap: a case report.

Despite the sacrifice of rectus abdominis muscle, the vertical rectus abdominis musculocutaneous (VRAM) flap is still a preferred option for perineal reconstruction. This journal has previously reported on the utility of preoperative computed tomographic angiography (CTA) in this setting to identify cases that are both suitable and unsuitable for rectus abdominis flaps after previous surgery. We report a case which highlights a unique example of the benefits of such imaging, with the largest deep inferior epigastric artery (DIEA) perforator described to date identified on imaging, and used to potentiate a donor-site sparing procedure. The use of this dominant perforator was able to limit donor site harvest to only a small cuff of anterior rectus sheath and a small segment of rectus abdominis, potentiating a muscle-sparing and fascia-sparing VRAM flap for perineal reconstruction. As such, preoperative CTA was found to be a useful tool in identifying a unique anatomical variant in the largest DIEA perforator described to date, and was used to potentiate a muscle-sparing and fascia-sparing VRAM flap for perineal reconstruction.

Why there are two rows of deep inferior epigastric artery perforators despite variability in the number of deep inferior epigastric artery trunks: An anatomical and embryological argument.

The deep inferior epigastric artery (DIEA) distributes musculocutaneous perforators in a uniform pattern that comprises "medial row" versus "lateral row" perforators, with these two rows having anatomical and functional differences. This pattern of two perforator rows is distributed from the DIEA regardless of the number of major DIEA trunks, with there variably being one to four major trunks. As such, a single DIEA trunk will still distribute two perforator rows, as will four major DIEA trunks. What remains to be answered is how such an anatomical fact may come to be? The answer probably lies in the anatomy and embryology of the rectus abdominis muscle itself. With two muscle heads to each hemiabdominal rectus abdominis muscle present from early in its development, it is highly likely that each head of rectus abdominis muscle draws its own blood supply from its source DIEA pedicle, one "perforator row" for each head, regardless of DIEA branching pattern from which these rows are drawn, thus providing an embryological and anatomical basis for the observation of two uniform perforator rows.