The surgical treatment of hypertrophic intertriginous Darier's disease.

Darier's disease is a rare autosomal-dominant genodermatosis characterised by persistent hyperkeratotic papules and plaques in seborrhoeic areas. The flexural areas of the body are especially difficult to treat, and they are often resistant to current topical and systemic treatment strategies. To our knowledge, this article provides the first description of a successful surgical treatment of a severely debilitating, hypertrophic Darier's disease of intergluteal area, resistant to oral retionids. A 25-year-old male patient was successfully treated with the use of tissue expanders and diseased skin excision. There are no signs of recurrence of the disease in the perianal region 6 months postoperatively, and there is a good result in functional as well as cosmetic terms. The formation of new skin on the excision site was observed, and there were no evident signs of infection. These encouraging results suggest that a patient who responds poorly to conventional treatment in a specific area should be presented to the plastic surgeon at an earlier point in time. Therefore, unnecessary hospitalisations, antibiotic treatments, dose-related adverse effects of oral retionids can be avoided, and eventually a long-term result can be achieved.

Ingrowth of sensory axons into an end-to-side coapted nerve stump after donor nerve crush in the rat.

BACKGROUND: Target innervation through an end-to-side (ETS) nerve coaptation depends on axonal sprouting from the donor nerve. Terminal axonal sprouting in a partially denervated target tissue is more extensive from a crushed donor nerve than from an intact donor nerve. We hypothesized that axonal sprouting into an ETS coapted recipient nerve could be stimulated by crushing the donor nerve. METHOD: Twenty-seven rats were randomised into 3 groups. In all, the distal stump of the transected peroneal nerve was sutured to the side of the sural nerve in place of the epineural window. The control group received no additional treatment. In the experimental groups, the sural donor nerve was crushed either 8 mm proximal (proximal crush group) or 8 mm distal to the coaptation site (distal crush group). Sixteen weeks after the surgery, histomorphometric analysis of the recipient peroneal nerve stump 4 mm distal to the coaptation site was performed. FINDINGS: The number of myelinated axons in the recipient peroneal nerve stump was 758 +/- 247 in the control group, 503 +/- 246 in the distal crush group and 211 +/- 96 in the proximal crush group. The differences between the groups were statistically significant (p < 0.05). The majority of myelinated axons were thin myelinated axons and the frequency distribution of their cross-sectional areas was similar in all groups. CONCLUSION: Contrary to our expectations, a significantly lower number of myelinated axons were present in recipient nerves in the proximal and distal crush groups than in the control group. This suggests that sensory axon ingrowth into an ETS coapted nerve cannot be enhanced by crushing the donor nerve.

Nerve fibre composition of the palmar cutaneous branch of the median nerve and clinical implications.

Fifteen fresh human cadaver hands were dissected, using x2.8 loupe magnification, to study the subcutaneous innervation at the site of the incision (in the line with the radial border of the ring finger) for standard open carpal tunnel decompression. Subcutaneous nerve branches were detected and traced proximally to determine their origin. Morphometric analysis of nerve cross sections from the site of the incision and from the main nerve trunk proximal to cutaneous arborisation was performed using light and transmission electron microscopy and a computer-based image analysis system. At the site of the incision, the ulnar sub-branch (US) of the palmar cutaneous branch of the median nerve (PCBMN), which innervates the skin over the hypothenar eminence, was found in 10 of 15 cases. Branches from the ulnar side were not detected. The main trunk of PCBMN consisted on average of 1000 (SD 229) myelinated axons arranged in 1-4 fascicles. In the US of the PCBMN there were on average 620 (SD 220) myelinated axons, 80% of them smaller than 40 microm(2) i.e. thin myelinated axons, and on average 2037 (SD 1106) unmyelinated axons, arranged in 1-3 fascicles. The ratio of the number of myelinated axons in the US and the main trunk of the PCBMN was on average 63% (SD 19%). Frequency distribution of cross-sectional areas of myelinated axons shows no significant difference between the US and the main nerve trunk of the PCBMN. The importance of incision trauma to subcutaneous innervation of palmar triangle is emphasised and possible mechanisms of scar discomfort are discussed.