Peripheral neuropathy in HIV patients: treatment by decompression of peripheral nerves.

Peripheral neuropathy is the most common nerve disorder in human immunodeficiency virus (HIV) patients. Distal symmetrical sensory polyneuropathy (DSP) affects roughly one third of HIV patients. With the introduction of antiretrovirals, more patients are surviving longer, and chronic complications are surfacing. Three consecutive patients with at least a 5-year history of HIV presented during the period from 2007 to 2009. All three patients were on antiretrovirals and had no other comorbid conditions such as spinal pathology or diabetes. All patients had symptoms of pain, numbness, and weakness. Quantitative sensory testing and/or electromyography/nerve conduction testing (EMG/NCT) were performed preoperatively and correlated with the presence of Tinel signs. Targeted nerve releases were performed in four extremities, for a total of 18 nerves. All three patients had symptomatic improvement at 1 year with a visual analog scale (VAS) reduction in pain by at least five points. Quantitative sensory testing showed improvement, as did two EMG/NCTs obtained postoperatively. This showed improvement in conduction velocity at the fibular tunnel and posterior tibial nerve at the tarsal tunnel. This is the first report of nerve decompressions in the lower and upper extremity of HIV patients in the literature outside of the median nerve in the carpal tunnel.

The subcutaneous cervicofacial flap revisited.

The cervicofacial flap has been the reconstruction of choice for midface soft tissue defects for over 30 years. Deep plane dissection has been advocated to decrease complication rates and improve results. However, the subcutaneous approach is still widely used. Over a 20-year period, we reviewed all patients who underwent subcutaneous cervicofacial flaps for cheek defects to analyze complications and results.Thirty-two patients (mean age, 71 years) underwent 32 subcutaneous cervicofacial flaps for cheek reconstruction after Mohs micrographic excision of skin cancer. The mean defect size was 7.2 x 5.8 cm. Mean follow-up was 32 months. Only 3 of 32 patients (9%) had minor flap tip or edge necrosis, all managed without further surgery. One patient (3%) had minor long-term ectropion with upward gaze and 31 of 32 patients were happy with their results.The subcutaneous rotation-advancement cervicofacial flap remains an excellent choice for cheek reconstruction with comparable tip necrosis rates and likely lower ectropion rates when compared with the deep plane technique.

Effect of augmentation mammaplasty on breast sensation.

BACKGROUND: Studies of alterations in breast sensibility after augmentation mammaplasty have produced conflicting results. Such discrepancies may be attributed to unsophisticated measuring devices used in earlier studies leading to less accurate measurements and to the comparison of results to different surgical techniques. The primary purpose of our study was to conduct a prospective clinical trial to quantify specific sensory outcomes before and after submuscular breast augmentation. METHODS: Preoperative and postoperative questionnaires were used to assess patients' subjective observations on breast sensation. Quantitative data were collected using a very accurate device, the Pressure-Specified Sensory Device, to assess objective breast sensation. Thirty-three micromastia patients underwent quantitative measurements preoperatively (baseline), at 2 to 4 weeks and 6 months postoperatively to assess breast sensitivity. RESULTS: The quantitative data showed similar patterns of sensory change between both the periareolar and the inframammary surgical approach over time. The inferior region was the only region that showed a diminished sensitivity threshold of 9.5 +/- 2.9 gm/mm2 for the inframammary incision, a significantly poorer average than the periareolar incision of 1.7 +/- 0.6 gm/mm2 with p = 0.008 at 6 months. Older patients had significantly higher thresholds of sensitivity compared with younger patients (p < 0.02). CONCLUSIONS: Our study suggests that the periareolar incision may produce less sensory loss in the lower pole of the breast when compared with the inframammary incision. The outcome of this study provides both the surgeon and the patient with concrete information regarding mammary sensation after augmentation mammaplasty and leads to a better informed-consent process.

Catfish spine envenomation: a case of delayed presentation.

Catfish spine envenomations can result in debilitating hand problems. Virulent bacteria may be introduced through a puncture wound. An offending organism may be difficult to culture, and a foreign body may be missed unless there is a high index of suspicion. The majority of cases present early and symptoms resolve within 3 months. We report a markedly delayed presentation and treatment of a catfish "finning" injury that resulted in chronic tenosynovitis to the hand. A review of the literature and current treatment recommendations are provided.

Vascularized medial sural cutaneous nerve based on the superficial sural artery: a reliable nerve graft.

The sural nerve is nourished by the single superficial sural artery proximally, but distally receives multiple contributions from musculocutaneous and fasciocutaneous perforators of the posterior tibial and peroneal (fibular) arteries. The prevalence of this proximal arterial supply is largely unknown. The authors report a large anatomic study (n = 56), together with two clinical cases, to assess the incidence and potential suitability of the sural nerve as a vascularized nerve graft. Dissections were performed on 6 fresh cadavers injected with Microfil dye and on 22 preserved cadavers. The superficial sural artery was present in 91 percent of the dissections. The mean diameter of this extrinsic artery was 1.5 mm. The mean percentage of neural tissue within the sural nerve in the region where it is supplied by the superficial sural artery was 62 percent compared to 34 percent distally, where it was supplied by the posterior tibial and fibular (peroneal) arteries. This anatomic difference provides a solid rationale for preferential utilization of the proximal portion of the nerve, as opposed to its distal segment. When a vascularized nerve graft is indicated, the proximally-based sural nerve appears to offer clear advantages, compared to other vascularized nerve grafts.