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SEPTEMBER 2016 | The Surgical Technologist | 409 ic balloon offers larger size of balloons, allowing for a better functioning esophagus and longer intervals between dilations, as well as less oropharyngeal trauma. 2 Patients with bad oral care also have an increased risk of bullae formation, oral ulcer- ation, poor mastication, diminished appetite and poor nutri- tion, which leads to an increased need for a gastrostomy tube. Gastrostomy tube placements are associated with dysphagia and esophageal strictures. Its primary purpose is to increase quality of life and help the patient maintain proper nutrition. However, this is seen as a last resort for patients with EB, as normal ingestion of food is encouraged. While either open or percutaneous gastrostomies may be performed, most patients do better with eventually replacing them with low profile gas- trostomy buttons. EB patients are at higher risks for infection and rejection due to the breakdown of tissues surrounding the gastrostomy site. 2 Hand and Foot Procedures The hands and feet are most commonly affected by EB, leav- ing patients with blisters and ulcerations, erosion, scars and the absences of nails. As mentioned previously, pseudosyn- dactyly is very common. Pseudosyndactyly typically forms as a result of epithelization, healing by growth of epithelium over the injured site, after recurrent epidermal injuries. Over time, a layer of epithelium forms between the digits, as well as around the whole hand, causing the hand to contract. This is also called “web creep” or “cocooning of the hand,” and starts in childhood. 9 Procedures to correct pseudosyndactyly are the most common surgical procedures among patients with EB. Even newborns are afflicted pseudosyndactyly as a result of intrauterine movement or trauma from the delivery. 3 Since this is a genetic disorder that affects the epidermal cells, it may become necessary to have repeated hand surgery on average every 2.5 years. The older technique of degloving has been replaced with a limited approach of interphalangeal and palmar contracture releases. Removal of the upper, hard- ened dermal layers, or degloving, traumatizes the lower lay- ers, resulting in more webbing. The limited approach simply dissects the tissue between the phalanges to return mobility. While full mobility not achieved, it is less traumatizing to the epidermal layers and increases time between surgeries, which is better for the quality of life of the patient. 9 In some cases, the muscle layers are exposed and a full thickness skin graft may be required. Despite the possible complications with har- vesting skin, cleaning and defatting the graft and suturing the graft, FTSGs typically heal well and are used when necessary. The graft is placed on a piece of greased tulle – commonly used as burn wound dressing – and placed over the receiver site. Many surgeons choose to leave the dressing on and wrap the wound in place of suturing. 9 The tulle dressing can be used over the donor site as well. After surgery, post-operative splinting and careful place- ment of dressings will be necessary for a time to prevent re-webbing during the healing process. Typically, the hand is wrapped using a soft bandage to provide downward pull on the web spaces and around the palm. The open wounds will first be covered with non-adherent dressings, and then the hand is prepared with a layer of emollient – a non-cosmetic moisturizer – before the application of the bandage. 3 Web- bing, and eventually digital fusion, frequently occurs that as adults many EB patients begin to refuse surgical treatments and live with the limited mobility caused by pseudosyndac- tyly. While the feet often are affected by shearing and blister formation, many surgeons recommend against any surgical procedures to correct webbing between the toes, as healing after surgery is usually difficult and the procedures show no long-term success. 3 Dermatological Procedures Despite the severe involvement of the skin, most forms of skin cancer do not affect patients with EB any more than the normal population. However, patients with EB have an elevated risk of squamous cell carcinoma or SCC. 2 SCC is typically seen in patients with more severe forms of EB, and appears mainly over boney prominences. Due to the decreased immune response and altered skin cells, SCC is typically aggressive and occurs in the majority of all EB patients who reach adulthood. 2 Several treatment options include the most common, less-invasive treatment such as radiotherapy or chemotherapy. However, some surgeons feel these treatments may weaken the good skin cells, making surgical treatment later on more difficult. Some doctors may choose to perform a Mohs proce- dure if they feel the SCC is more isolated. The Mohs proce- dure involves surgically removing an area of skin and then examining the tissue layer by layer to ensure the margins are clear. While this can take some time, it is considered one of the better treatments for skin cancer, and is fairly safe for patients with EB as it is performed as an outpatient procedure while the patient remains awake. Reconstruction after Mohs typically involves a primary closure for smaller wounds or a full thickness skin graft for larger wounds, which has proven to be successful in the majority of cases. 2 Since many patients with EB struggle with malnutrition,