Craft, Randall O.

Merkel cell carcinoma (MCC) is a rare and biologically aggressive neuroendocrine tumour of the skin. Recent analysis of a surveillance, epidemiology and end results program has shown a statistically significant increase of 8% per year in the age-adjusted rates for MCC of the skin over the past 15 years. MCC commonly presents as a painless, rapidly growing, single red or purple cutaneous nodule. Diagnosis is often delayed until histopathological examination due to the relative rarity of the disease. MCC-specific immunohistochemical markers are available for definitive diagnosis, including anticytokeratin-20-positive stain and thyroid transcription factor-1-negative stains. Because there are no phase III trials to guide management, treatment is often tailored to the individual patient by integrating surgery, radiation and chemotherapy.

INTRODUCTION Acellular dermal matrices have been used with increasing frequency in both reconstructive and cosmetic surgery. While many studies have described the safety and morbidity profiles of these materials, little is known about the relative mechanical properties of individual sheets of allograft harvested from distinct donors. METHODS Sixty-two individual sheets of an acellular dermal matrix from distinct lot numbers (signifying different donors of the dermis) were prospectively analyzed before use. Distribution of thickness according to manufacturer specifications in the dry state were as follows: 0.009 inches to 0.013 inches (1 [1.6%]); 0.79 mm to 1.78 mm (3 [4.8%]); 0.79 mm to 2.03 mm (5 [8%]); 0.8 mm to 3.3 mm (1 [1.6%]); 1.8 mm to 3.3 mm (10 [16.1%]) and 28 mm (6 [9.7%]). The size of the matrix was recorded while dry, after hydration and following stretch. The percentage change in surface area was recorded for each lot. RESULTS The 62 reconstructive cases included breast implant reconstruction (2 [3.2%]); ventral hernia repair (11 [17.7%]); abdominal closure following autologous tissue harvest (6 [9.6%]); autologous breast reconstruction (37 [59.6%]); extremity wound closures (3 [4.8%]) and reinforcement of vertical rectus abdominis muscle closure (3 [4.8%]). The mean percentage change in the size of the acellular dermal matrix to the hydrated state was 58% (36 of 62; thickness 0.06 mm to 3.30 mm); the mean percentage change in size from dry state was 7.14% (range 0% to 18.7%). The mean percentage change in the size of the hydrated matrix to the stretched state was 25.7% (range 0.25% to 70.6%). The variability in elasticity among the individual sheets was significant (P<0.0005). CONCLUSION The acellular dermal matrix displayed highly variable elastic properties among distinct donors. This may be significant in procedures in which symmetry is critical.

A retrospective chart review for the period between 1998 and 2006 was conducted to evaluate microneurolysis combined with a hypothenar fat pad flap (HTFPF) for patients at Mayo Clinic, Scottsdale, Arizona, who were being treated for recurrent carpal tunnel syndrome. After exclusion of patients with incomplete release of the transverse carpal ligament at the time of the original operation, 28 consecutive patients were identified. Their average age was 68.5 years (range 43–89 years). The average interval between the original carpal tunnel release and reexploration was 82 months (range 5–298 months). The average follow-up was 10.5 months (range 3–48.4 months). The preoperative two-point discrimination tests averaged 7 mm (range 5–12 mm). At surgery, all patients were found to have fibrosis surrounding the median nerve with adherence of the nerve to the radial leaf of the transverse carpal ligament. After surgery, the Tinel sign disappeared in 26 of 28 patients and two-point discrimination improved to an average of 6 mm (range 4–8 mm). Postoperative grip strength averaged 20 kg, compared with 11 kg preoperatively. Pain completely disappeared in 83% of patients (average improvement 93%, range 5–100%). Numbness completely disappeared in 42% of patients (average improvement 82.9%, range 5–100%). Tingling disappeared in 50% of patients (average improvement 84.7%, range 5–100%). No patient reported being worse after reoperation. These results suggest that the combination of microneurolysis and HTFPF can restore median nerve gliding and provide soft-tissue coverage, improving symptoms in patients with recurrent carpal tunnel syndrome.

Because physician turnover, especially during the first 5 years after joining a practice group, has been reported to be as high as 54%, we sought to identify and quantify the factors that lead hand surgeons to leave their practices. An eight-question practice survey was administered to 10 hand surgeons, all of whom had left their practices under various circumstances. All respondents were men (mean age, 43.2 years). Nine surgeons were in their first practice and one was in his second. Time in the practice ranged from 4 months to 6.5 years (mean time, 3.4 years). Questions about surgical practice issues were asked of all survey participants, who were then asked to quantify the influence of the issue on their decision to leave their own surgical practice with a Likert scale ranging from 1 (no influence) to 5 (greatly influenced the decision to leave). The strongest influences on the decision to leave a practice were interpersonal conflict (mean, 4.7 points) and lack of decision-making ability within the practice (mean, 4.2 points). The influence of partnership determination (mean, 3.3 points) was mixed, whereas staff support (mean, 2.9 points), salary agreements (mean, 2.4 points), employment contracts (mean, 1.6 points), and retirement benefits (mean, 1.0 points) played a lesser role in the surgeons' decisions to leave their practices.