METHODS: The authors describe a modified second toe transfer that addresses cosmesis in six patients. These include (1) harvesting a flap from the adjacent side of the great toe and insetting it into the volar aspect of the second toe to give more bulk, (2) making skin excisions on each side of the tip to reduce the bulbous appearance, and (3) excising the eponychium to produce apparent lengthening of the nail.
RESULTS: The mean follow-up period was 18 months (range, 6 to 36 months). The procedure resulted in good function and improved cosmesis in all six cases. Part of the great toe flap was lost in one case. The mean two-point discrimination in the transferred toes was 10.1 mm, with protective sensation present in the flaps. The range of motion of the transferred toe was 14 to 38 degrees at the metatarsophalangeal joint, 16 to 55 degrees at the proximal interphalangeal joints, and 20 to 36 degrees in the distal interphalangeal joints. All patients except one were happy with the appearance of the transferred toe.
CONCLUSION: This novel approach will allow patients to take advantage of the lower morbidity to the donor site afforded by second toe-to-thumb transfer and provide the patients with a more aesthetic appearance of the new thumb.
OBJECTIVE: To investigate the effects of electrical stimulation of the tragus on autonomic outputs in the rat and probe the underlying neural pathways.
METHODS: Central neuronal projections from nerves innervating the external auricle were investigated by injections of the transganglionic tracer cholera toxin B chain (CTB) into the right tragus of Wistar rats. Physiological recordings of heart rate, perfusion pressure, respiratory rate and sympathetic nerve activity were made in an anaesthetic free Working Heart Brainstem Preparation (WHBP) of the rat and changes in response to electrical stimulation of the tragus analysed.
RESULTS: Neuronal tracing from the tragus revealed that the densest CTB labelling was within laminae III-IV of the dorsal horn of the upper cervical spinal cord, ipsilateral to the injection sites. In the medulla oblongata, CTB labelled afferents were observed in the paratrigeminal nucleus, spinal trigeminal tract and cuneate nucleus. Surprisingly, only sparse labelling was observed in the vagal afferent termination site, the nucleus tractus solitarius. Recordings made from rats at night time revealed more robust sympathetic activity in comparison to day time rats, thus subsequent experiments were conducted in rats at night time. Electrical stimulation was delivered across the tragus for 5 min. Direct recording from the sympathetic chain revealed a central sympathoinhibition by up to 36% following tragus stimulation. Sympathoinhibition remained following sectioning of the cervical vagus nerve ipsilateral to the stimulation site, but was attenuated by sectioning of the upper cervical afferent nerve roots.
CONCLUSIONS: Inhibition of the sympathetic nervous system activity upon electrical stimulation of the tragus in the rat is mediated at least in part through sensory afferent projections to the upper cervical spinal cord. This challenges the notion that tragal stimulation is mediated by the auricular branch of the vagus nerve and suggests that alternative mechanisms may be involved.