Using a Distant Abdominal Skin Flap to Treat Digital Constriction Bands: A Case Report for Vohwinkel Syndrome

In this study, a Vohwinkel syndrome case is presented where in 5th digit constriction bands in the right hand were reconstructed using a distant abdominal skin flap. Vohwinkel syndrome, or keratoderma hereditarium mutilans, is a rare, autosomal dominant genetic skin condition that causes palmoplantar hyperkeratosis and constricts finger and/or toe bands. In a typical manifestation, the finger and toe constriction bands lead to progressive strangulation and autoamputation, which requires immediate clinical treatment. Topical keratolytics and systemic retinoids have been used to treat hyperkeratosis but without consistent results. Only 1 effective approach for autoamputation has been accepted, reconstructive surgery.Applying a distant abdominal skin flap produced satisfying postoperative effects at the 18-month follow-up.

Effect of painful keratoses debridement on foot pain, balance and function in older adults

BACKGROUND

Painful feet in older people can detrimentally affect balance and are a risk factor for falls. Pain is often associated with plantar hyperkeratoses, which are easily treated by podiatrists. Currently, there is no data defining the effect this treatment has on balance or functional ability.

OBJECTIVE

To determine the effects of scalpel debridement of painful plantar hyperkeratoses on pain, balance and functional ability in older people aged 65 years and over.

SUBJECTS

Nineteen men and women aged 65-84 years (mean age 72, standard deviation 5.6).

METHODS

Pain resulting from plantar hyperkeratoses was measured using a visual analogue scale. Static balance and functional ability were measured using tests of postural sway, co-ordinated stability and timed walking and stepping tests. Painful plantar hyperkeratoses were debrided with a scalpel then all tests were repeated, immediately and 7 days later.

RESULTS

Following scalpel debridement, pain levels (sensory and afferent) were significantly reduced (P<0.0001) and functional ability was significantly increased (P<0.0001). There was no change in static balance ability. One week after debridement the improved performance in functional ability tests was maintained.

CONCLUSIONS

Debridement of painful plantar hyperkeratoses reduces pain and improves functional ability in older people. Its effect on static balance was inconclusive.

Acral Malignant Melanoma and Striated Palmoplantar Keratoderma (Brunauer-Fohs-Siemens Syndrome): A Fortuitous Association?

BACKGROUND

Striated palmoplantar keratoderma or Brunauer-Fohs-Siemens syndrome is a very rare, focal, nonepidermolytic palmoplantar keratoderma with autosomal inheritance. Unlike other palmoplantar keratodermas, no association with visceral or skin cancer has ever been reported.

OBJECTIVE

We report a case of malignant melanoma arising in the hyperkeratotic lesions on the right heel of a patient with striated palmoplantar keratoderma. The lesion was completely excised; our patient also underwent sentinel lymph node biopsy and then was treated with high-dose interferon adjuvant therapy.

METHODS

Sentinel lymph node biopsy incision was made in elliptical fashion, long enough to harvest a full-thickness skin graft to cover the wide local excision defect. The skin graft was defatted by sharp dissection. Several perforations were made in graft and it was secured in place with sutures and bolster dressing.

RESULTS

At follow-up, the grafted skin showed hyperkeratotic changes but no local or systemic signs of the disease was observed.

CONCLUSION

The association between striated palmoplantar keratoderma and acral melanoma is discussed.

Effect of scalpel debridement on the pain associated with plantar hyperkeratosis

Seventy-nine subjects from 14 centers in eight English National Health Service Trusts recorded their levels of preoperative and postoperative pain and perceived change in pain on 100-mm visual analog scales before and after scalpel debridement of painful plantar hyperkeratosis. A significant reduction in pain was reported following treatment, and there were highly significant differences between the preoperative and postoperative scores. There were no age- or sex-related differences in any of the preoperative, postoperative, or perceived-change scores. The objective data support the anecdotal evidence that scalpel debridement of painful plantar hyperkeratosis is immediately effective in the palliative management of such patients.

[Surgical treatment of excessive hyperplasia symptom of skin keratosis at the limb ends]

OBJECTIVE

We introduce the experience of treating 10 cases with excessive hyperplasia of skin keratosis at the limb end. There were 9 cases of palmar and plantar keratosis and 1 case of epidermodysplasia verruciformis.

METHOD

All cases received the operation of lesion excision and skin grafting except 2 cases who received skin flap for defect covering after lesion excision because of deep tissue exposure and postradiation ulcer.

RESULT

The operative effects were satisfactory after 8 years of follow-up. No recurrence was found in all cases and all patients resumed normal activity.

CONCLUSION

The effect of the skin flap is better than skin graft at the plantar area. Because of lack of fibrous septum in the subcutaneous tissue, the flap, often moving during walking, is liable to trauma and ulceration. The operation area must be well protected.

Surgical correction of pseudo-ainhum in Vohwinkel syndrome

Vohwinkel syndrome or hereditary mutilating keratodermatitis is a rare condition producing palmoplantar hyperkeratosis and constricting rings of the fingers and toes which can progress to compromise neurovascular function and mobility. Medical treatment with oral retinol derivatives is recommended when its use is not contra-indicated. This paper describes surgical correction of the constricting rings on both hands in a 33-year-old woman affected by this condition.

[Classification of limited hyperkeratoses]

A classification of limited hyperkeratoses (LH) was developed for practical use in out-patient surgical practice on the basis of literature data and personal studies and observations over 630 patients. Hyperkeratoses are classified according to the etiological sign (mechanical damage to the skin, diseases and deformities of the locomotor apparatus-neurotrophic, genetic, miscellaneous), clinical course (acute LH-soft corn, uncomplicated and infected and chronic LH-dry corn or callus, uncomplicated and complicated with suppuration, formation of fistula, malignization), according to shape (spherical, ellipsoid, cone-shaped), according to localization (hand and foot, unilateral, bilateral, combined, palm, finger, toe, interdigital), according to size (small, moderate, large), and according to number (solitary, multiple). The cause of the disease in 452 patients was the mechanical effect of poorly fitting shoes and trauma caused by various objects. In 19 patients LH occurred as the result of a pathological condition of the locomotor apparatus (exostosis, flexion contracture of the toes, amputation stump, etc.). In 70 cases LH was a consequence of diseases of the peripheral nervous system. There were rare causes in the remaining patients. Various methods of treatment are suggested, including the use of a laser scalpel, depending on the classification signs of the disease. Removal of the etiological factors is a very significant measure in the treatment and prevention of LH.

[Methods and effectiveness of surgical treatment of limited hyperkeratoses with CO2 laser]

A method for surgical treatment of limited hyperkeratoses (LH) with CO2 laser was elaborated. Its essence consists in complete "evaporation" of corns within the boundaries of healthy tissues by means of a CO2 laser. Laser excision of LH was conducted in some patients. The method was applied in the treatment of 502 patients with LH with a favorable clinical effect: the immediate results improved, the reparative processes in the wound developed more rapidly in 96% of cases, the period of inability of the patients reduced to one fourth. No complications occurred. Recurrences were noted in the late-term postoperative periods only in 4% of cases. A good cosmetic result was produced in most patients. The economical effect of the method was 36 thousand roubles.

Proximal metatarsal segmental resection: a treatment for intractable plantar keratoses

For the past 15 years, a procedure the authors have termed proximal metatarsal segmental resection has been used for the treatment of intractable, painful, submetatarsal plantar keratoses which have failed nonoperative treatments. This simple procedure basically is the resection of a cylindrical segment of proximal metatarsal bone approximately 0.5 cm long. Fifty-four patients (70 metatarsals) underwent the procedure and were followed a mean of 6 years. Good to excellent results were reported in 89% of these patients. Transfer lesions occurred in 18% of feet and were responsible for all fair and poor results. When the procedure was carried out in association with a bunion correction, transfer lesions occurred in 23%; whereas when performed as an isolated metatarsal procedure, transfer lesions followed in 12%. Recurrent keratoses developed in 7%. This technically simple procedure is associated with minimal patient morbidity and should be considered an option in the surgical management of metatarsalgia.

[Problems in surgery of the sole of the foot]

The structure of the weight-bearing plantar skin and the subcutaneous cushion is adapted to mechanical loads of 3-10 kp/cm2 under walking conditions. Such loads, however, are only tolerated when compensated by constant alternation of loaded points. If the surgical therapy with free skin grafts or pedicled flaps does not take into account the vascular and neural architecture of the plantar skin, healing without problems may result--but only for a short time. As a rule, such grafting is later followed by painful keratotic lesions or non-healing "trophic" ulcers, which are caused by loss of sensitive innervation, changing of loaded points as well as the specific subcutaneous architecture. Therefore, reconstructive surgery of loaded plantar skin often requires innervated musculo-cutaneous flaps. Plantar warts or other benign lesions with possible regression are not indications for grafting at all.

Mutilating palmoplantar keratoderma with periorificial keratotic plaques (Olmsted's syndrome)

We report the case of a boy, now aged 4 years, with a progressive, painful and disabling palmoplantar keratoderma, associated with well-defined hyperkeratotic plaques around the mouth and nostrils. His mother has an identical palmoplantar keratoderma. The palmoplantar keratoderma failed to improve with etretinate, but considerable benefit resulted from full-thickness excision of the skin of both palms, followed by skin grafting. We believe that he has a distinctive but extremely rare form of hereditary palmoplantar keratoderma, first described by Olmsted.

Surgical treatment of epidermolytic hereditary palmoplantar keratoderma

We report the case of a man with epidermolytic hereditary palmoplantar keratoderma. After failure of topical and systemic therapy, excision and skin grafting of both hands was done in several steps. Attention must be given to the skin-repair procedures (split- or full-thickness grafting), and the exact setting of the suture lines in the fingers is important.

Distal oblique osteotomy for intractable plantar keratosis of the middle three metatarsals

On the middle metatarsals of 49 patients with symptomatic intractable plantar keratosis, 69 distal oblique osteotomies were performed. With an average follow-up time of 16 months, 83% of the results were rated good. This procedure is contraindicated for an intractable plantar keratosis with an associated fixed metatarsphalangeal joint deformity, however.

Plastic surgery for the management of palmoplantar keratodermia (palmoplantoneoplasty)

Keratodermia is an incurable genetic and regional disease located in the palmar and plantar regions. The author reports his experience with five cases of palmoplantar keratodermia that were treated by grafting onto the soles and the palms skin taken from the calves and the thighs.

Keratoma hereditaria mutilans: report of a case with successful surgical treatment

A case of constriction band at the fingers arising from keratosis palmoplantaris is reported. Excision of the band and closure of wound by Z-plasties resulted in complete relief of clinical symptoms and vascular insufficiencies. Histologic examination revealed the variability of this skin lesion even in the same patient. The sparsity of keratohyaline matrix in the horn cells in the skin may contribute to the constriction ring formation.

Richner-Hanhart syndrome spares a plantar autograft

A patient with Richner-Hanhart syndrome had thigh skin grafted onto her heel in an attempt to improve her walking. The graft seemed to be spared by the hyperkeratosis that arrested at the periphery of the graft and formed a keratotic wall. A low-tyrosine, low-phenylalanine diet was effective in clearing hyperkeratosis.

The resistant, painful, plantar lesion: a surgical approach

Osteotomies designed to lift the metatarsal head dorsally on the sagittal plane are performed to alleviate painful plantar lesions beneath the metatarsal head. Correcting the position of the bone reduces the plantar pressure and stresses that are believed to cause the painful lesions. The authors found that resistant plantar lesions secondary to a plantarly depressed or long lesser metatarsal responded to a combination of plantar excision and modified cartilaginous articulation preservation osteotomy procedure.

Surgical correction of hyperkeratosis in the Papillon-Lefèvre syndrome

In a severe case of the Papillon-Lefèvre syndrome, surgical correction of the disabling hyperkeratosis on the dorsa of the hands was first tested in a small area and, when that proved successful, the entire dorsa of both hands were resurfaced. The result was functionally gratifying and the cosmetic appearance was improved.

Biwinged excision for closure of rounded defect

A new technique for closure of rounded defects is described. The biwinged procedure consists of excising two equal triangles on either side of the defect, one above and one below the dissecting line. Closure is in the form of a step. It can be made to parallel in part a wrinkle or contour line, such as a nasolabial fold, a temporal region above and beside the eyebrow, an area over the lower border of the mandible, or on the dorsum of the hand. A mathematical comparison of the amount of healthy tissue in the biwinged excision and in six other procedures is presented.

A new method of excision of painful plantar forefoot lesions using a rotation advancement flap

A new method of excision of painful plantar lesions in the forefoot was studied in 13 feet (12 patients). Etiology of the lesions was variable, including traumatic and iatrogenic scars. Localized transfer of partially undermined tissue is used to fill a triangular defect created by excising the lesions. The flap is advanced/rotated into place, without gapping or tension. Full sensation is maintained and because of the significant vascular contribution by the proximal plantar subcutaneous plexus, there is little chance of vascular compromise. Problematic scars occurred in only three feet (two patients). Complications included inclusion cysts in two cases, one parakeratotic nodule and an incidental occurrence of verruca in one case. Follow-up average was 25 months. This procedure provides an alternative method for resolving patients' painful plantar lesions.