Savaş Serel

Self-mutilation (self-harm or self-injury) is any intentional injury to one's own body most often done without suicidal intentions. The most common form of self-mutilation is skin cutting. Munchausen's syndrome is an extreme type of factitious disorder in which the individuals seek for medical help for factitious illnesses to draw attention and sympathy. In this case report we present a 40 years old male patient with self-inflicted wrist cut who imitated the symptoms of tendon and nerve injuries. [Hand Microsurg 2014; 3(3.000): 83-86

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity. This disease is commonly observed in women, particularly those of reproductive age. The pelvis is the most common location for endometriosis. On the other hand, extrapelvic endometriosis, which is less common, is more difficult to diagnose because of the extreme differences in its presentation. In this article, we describe our experience of a case of endometriosis in an abdominal wall scar. Keywords: Endometriosis. Skin abnormalities. Cicatrix/complications. Abdominal wall. INTRODUCTION Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity. This condition is commonly observed in women, particularly those of reproductive age; it has been estimated that endometriosis occurs in nearly 6–10% of women 1 . The pelvis is the most common location of the disease, resulting in the common presenting symptoms of pelvic pain, dysmenorrhea, dyspareunia, cyclical bowel or bladder symptoms, and infertility. On the other hand, extrapelvic endometriosis, which is less common, is more difficult to diagnose because of the extreme differences in its presentation. Cutaneous endometriosis is one of the possible extrapelvic types of the disease, but physician ignorance on the subject often results in the diagnosis being delayed or missed. Cutaneous endometriosis involving the abdominal wall is rare. During preoperative diagnosis, cutaneous endometriosis can be easily mistaken for a suture granuloma, lipoma, abscess, cyst, or hernia 2 . The differential diagnosis of a skin lesion on the abdominal wall is important because of the possibility that it is malignant. The majority of reported abdominal wall endometriomas have been noted in and adjacent to scars resulting from cesarean section. Primary cutaneous endometriosis has also been documented. The incidence of cesarean scar endometriosis is between 0.03% and 1.7%, but clinical experience suggests that the actual incidence may be higher 3 . Symptoms such as pain and edema are known to worsen with menstruation; however, in many clinical series studying endometriosis, cyclical pain was not reported. In this article, we report a case of abdominal wall scar endometriosis. The definitive diagnosis was determined after histopathological study. CASE REPORT A 41-year-old woman presented to our department because of a mass in the right lower abdominal area for the past 1 year. It was first noted as a lump at the right lower abdomen on the right lateral side of a previous cesarean scar. The mass was associated with persistent pain and was increasing in size. The patient did not have a history of cyclical pain. However, she had a cesarean section 5 years ago. On examination, we noted a hyperpigmented area at the right lateral side of the cesarean scar, above the mass ( Figure 1 ). The clinical diagnosis of a subcutaneous abdominal wall mass was made and the patient underwent surgery. The operation performed was a wide local excision. Grossly, it was a black nodular mass with a fibrous cystic formation measuring 4.5 × 4.5 × 2.7 cm in the dermis and subcutaneous tissue. Microscopically, there were multiple micronodules composed of benign endometrial glands and stroma within the reticular dermis and subcutaneous adipose tissue ( Figure 2 ). There were no malignant cytological features. Immunohistochemistry was performed on tissue sections using a Ventana Automated Immunostainer. The antibodies used included antibodies for CD10 (56C6, 1:75; Novocastra), progesterone receptor (PR) (SP2, 1:300; Neomarkers), and estrogen receptor (ER) (SP1, 1:100; Cell Marque). Immunohistochemically, CD10 expression was only observed in the stromal component, whereas ER and PR expressions were noted in the glands and stroma. DISCUSSION Cutaneous endometriosis was first described by Villar in 1886 4 . A century after Villar, there have been many theories proposed as to the cause of endometriosis. The theory of retrograde menstruation (also called the implantation theory or transplantation theory) is the most commonly accepted theory for the formation of ectopic endometrium 5,6 . It describes the pathological process as an attachment of endometrial debris to the peritoneal surface, which exits the uterus through the fallopian tubes during a woman’s menstrual flow. Another explanation, the coelomic metaplasia theory, is based on the fact that coelomic epithelium is the common progenitor of endometrial cells; it is suggested that transformation from one type of cell to the other is possible, perhaps in response to an inflammatory process. Endometriosis that occurs after operations on the uterus, such as hysterectomy, cesarean section, or myomectomy, supports the transplantation theory. In such cases, it is likely that the endometrial tissue was transplanted to the surgical scar area. In the present case, the patient had a history of cesarean section, but did not have a previous endometriosis complaint, thereby supporting the transplantation theory. The late onset of symptoms after surgery is a reason for misdiagnosis. The usual clinical presentation is of a parous woman complaining of a painful nodule at the incision site that varies with menses (which thus can prove the functional state of the endometrial tissue outside the uterine cavity). The average period between surgery on the uterus and the onset of symptoms has been reported to be between 4.5 years to 5.72 years in different studies 7,8 . However, some authors reported the onset of symptoms to be as early as 3 months or as late as 10 years. In our patient’s case, it was 3.5 years. Incisional scar endometriosis is a well-defined subject in the gynecology literature but is not well known among plastic surgeons. Preoperatively, most plastic surgeons consider these lesions to be suture granulomas, abscesses, or lipomas. Due to the increased rates of endometriosis and cesarean section, it is essential that we ensure optimal management of scar endometriosis. Surgical excision is both diagnostic and therapeutic in these cases. Wide surgical excision with secure margins is appropriate, and a histopathological examination should be performed, during and after the operation. The depth of cutaneous endometriosis can only be determined at the time of surgery, and total excision is the appropriate manner in which to achieve a cure. It is crucial to inform patients preoperatively about the possible placement of a mesh to repair the defect in the rectus sheath. Thus far, there have been some reports of the use of a Prolene mesh following excision of cutaneous endometriosis. In the present case, a suprafascial excision was performed. Malignant transformation of surgical scar endometriosis is rare; however, we should be aware of the possibility because it has been reported 9 . Educating all types of physicians, including general practitioners, is important to help in the diagnosis and surgical treatment of this rare condition. Moreover, plastic surgeons should consider this condition in female patients who present with a postoperative abdominal wall mass at the incision site.

The ideal technique to repair a damaged peripheral nerve is primary repair. Unfortunately, most damaged peripheral nerves have gaps making primary repair impossible. Autologous nerve grafts that are used to repair damaged nerves can either be conventional nonvascularized nerve grafts or vascularized nerve grafts. Vascularized nerve grafts are proposed to be superior to conventional nerve grafts especially in recipient beds that are scarred, with poor vascular supply. One of the disadvantages of vascularized nerve grafts is the limited donor site. It is possible to eliminate this problem by prefabricating vascularized nerve grafts. In this study, to prefabricate a vascularized nerve, segments harvested from left sciatic nerves of 10 Wistar albino rats were implanted on right femoral vessels, and intact right sciatic nerves were used as controls to evaluate the function, electrophysiologic studies, and histopathologic examination, were performed on these grafts 4 weeks after implantation. Prefabricated sciatic nerve grafts showed vascularization, but they did not show compound action potential activity to electrical stimulation and demonstrated diffuse and severe vacuolar degeneration and myelin loss. We were unable to prefabricate a functional vascularized nerve graft by this method.

We evaluated the effect of tirofiban hydrochloride on the survival of epigastric island flaps in rats that had had all the veins occluded. Male Wistar Albino rats were randomly assigned to control (treated with sterile saline) and experimental (treated with tirofiban hydrochloride 1 mg/kg intravenously) groups. An epigastric island skin flap 3x6 cm was raised in each rat. All veins that drained the flap were ligated to give total venous occlusion. Blood flow was recorded by laser Doppler preoperatively (baseline), immediately after the flap had been sutured back to its original position (acute) and on postoperative days 1 and 3. The degree of necrosis was evaluated on day 3. Mean percentage necrosis and minimum laser Doppler values were compared in the two groups. Total necrosis was evident on day 1 in the control group and on day 3 in the experimental group. Macroscopic evidence was confirmed by histopathological examination. There were appreciable differences in blood flow and in the necrotic area of the flap in the experimental group compared with the control group on both days 1 and 3. Tirofiban hydrochloride might be effective in this flap model.

The purpose of this report is to introduce the cross‐leg anterolateral thigh perforator flap for closure of a defect on the dorsum of the foot, and to show that the anterolateral thigh perforator flap is a safe option for a cross‐bridge microvascular anastomosis in defects of the extremity. The free anterolateral thigh perforator flap was used for a patient with an unhealed wound on the dorsum of the foot. The flap was revascularized by end‐to‐side anastomosis between the flap's artery and the posterior tibial artery of the other leg, since there was no available recipient artery on the same leg. After a 4‐week neovascularization period, the pedicle was cut. To the best of our knowledge, this is the first report of the use of a free anterolateral thigh perforator flap for a cross‐bridge microvascular anastomosis. © 2006 Wiley‐Liss, Inc. Microsurgery, 2006.

We investigated the appropriateness of the implant to be used in free-tissue transfers in a rabbit model in which a full-thickness skin graft was wrapped around a prefabricated high-density porous polyethylene implant. In ten New Zealand white rabbits, high-density porous polyethylene implants (Medpor), 10x15x3 mm in size, were bilaterally placed and anchored underneath the superficial inferior epigastric artery and vein pedicle under anesthesia. The flaps were prefabricated through vascular induction. Eight weeks later, the flaps were wrapped by a full-thickness postauricular skin graft, following orthotopic transplantation. Two weeks after grafting, full-thickness biopsy samples were obtained from the distal one-third of the implants and stained with hematoxylin-eosin and Masson trichrome for histologic examination. Graft compliance was observed in all the implants. Histologic sections showed rich fibro-neovascular tissue, neovascularization, and development of connective tissue cells. There were very few polymorphonuclear cells. No signs of inflammation were observed. Prefabrication of the high-density porous polyethylene implant under the superficial inferior epigastric artery and vein results in sufficient conditions for its use in free transfers.