Expanded full-thickness skin grafts in children: case selection, planning, and management

Resurfacing of Sleeve-Like Circumferential Giant Congenital Melanocytic Nevi on the Upper Extremity With Pre-Expanded Pedicled Flap

As the relative shortage of healthy tissue obviates the option of local soft tissue coverage, reconstruction of circumferential giant congenital melanocytic nevi (GCMN) on the upper extremity remains particularly challenging. Here the authors report a 3-stage procedure involving pre-expanded pedicled flap from the torso for the reconstruction of upper extremity after circumferential GCMN excision in pediatric patients. The giant nevus was completely removed and the size of the excised nevus was 31 × 14.5 cm. The donor site was primarily closed. No major complication was encountered. Reconstruction with expanded pedicled flap achieved satisfactory results, both functionally and cosmetically.

Effects of skin stretching without joint movement on skin extensibility of rats

[Purpose] This study examined the possibility of maintaining skin extensibility by stretching the skin involved in disuse joint contracture. [Subjects and Methods] The study was carried out using 18 male Wistar rats. The rats were randomly allocated to three groups. The control group received no intervention for the right ankle joint, the fixation group received one-week’s fixation of the right ankle joint in maximum plantar-flexion with a cast, and the stretching group received continuous stretching of the skin over the Achilles tendon for 30 min once daily for one week with the cast removed during the skin stretching, but the joint was not moved. On the final day, skin extensibility of the skin from the posterior aspect of the ankle joint was determined using a tensile strength tester and a length-tension curve. [Results] Statistical analysis of the data revealed significant differences in the skin extensibility among the three groups. The stretching group showed significantly greater improvement of skin extensibility than the fixation group. [Conclusion] Skin stretching without moving the joint was demonstrated to be useful for maintaining skin extensibility.

[The congenital melanocytic nevi of the face in child: What's new?]

Congenital melanocytic nevi of the face are a frequent reason for consultation in paediatric plastic surgery. Usually of small size, they raise a complex problem of reconstruction when they are large and giant. The indication of excision is generally stated on aesthetic criteria whereas the risk of melanoma is especially important in the giant nevi. Simple suture, full thickness skin graft and expanded skin flaps are the techniques of choice. The treatment must be carried out precociously, follow a surgical planning, respect the aesthetic units of the face and the periorificial areas, adapt to the age of the child and bring psychological benefit to the child.

Burns: treatment and outcomes

Burns can cause extensive and devastating injuries of the head and neck. Prevention of the initial injury must always be a priority, but once an injury has occurred, then prevention of progression of the damage together with survival of the patient must be the immediate goals. The acute care will have a major influence on the subsequent scarring, reconstructive need, and long-term outcome. In the majority of cases, the reconstruction will involve restoration of form and function to the soft tissues, and the methods used will depend very much on the extent of scarring locally and elsewhere in the body. In nearly all cases, a significant improvement in functional and aesthetic outcomes can be achieved, which, in conjunction with intensive psychosocial rehabilitation, can lead to high-quality patient outcomes. With the prospect of facial transplantation being a clinical reality, the reconstructive spectrum has opened up even further, and, with appropriate reconstruction and support, no patient should be left economically deprived or socially isolated after a burn injury.

Giant congenital melanocytic nevi

BACKGROUND

: Giant congenital melanocytic nevi are rare lesions with the potential to regress into malignant melanoma and/or neurocutaneous melanosis. Appropriate investigations include a screening magnetic resonance imaging scan, neurologic evaluation, and serial clinical observations looking for the development of these complications. Numerous excisional and nonexcisional options have been described for the management of giant congenital melanocytic nevi.

METHODS

: A MEDLINE search was performed to obtain all relevant citations.

CONCLUSIONS

: To successfully treat these complex lesions, the plastic surgeon must understand the disease process, the natural history and complications, and the options for treatment.

Congenital melanocytic nevi of the eyelids and periorbital region

BACKGROUND

Congenital melanocytic nevi of the eyelids and periorbital region are unusual. Although their malignant potential can be debated, they present a significant aesthetic concern and also disturb lid function. In this article, the authors present an expanded approach to evaluation and treatment of these patients.

METHODS

Forty-four consecutive patients, aged 6 months to 18 years, were treated from 1980 to 2008. All patients had congenital nevi involving one or both eyelids, with or without extension into the surrounding periorbital area and face. Follow-up ranged from 6 months to 20 years.

RESULTS

All patients were treated successfully with excision and reconstruction of their congenital eyelid and/or periorbital nevi. The involved ciliary border was preserved in all but one case, where the exophytic lesion presented function concerns. Complications included asymptomatic lateral ectropion in three patients. Asymmetry of the palpebral apertures, before treatment, was present in at least half of the patients with extensive facial nevi, and the abnormalities causing these differences may impact efforts to obtain final lid symmetry. A single patient died as a result of extensive metastatic melanoma from an extracutaneous site.

CONCLUSIONS

Early evaluation and treatment of these nevi may help in preventing the aesthetic, functional, and health-related issues for the patients. Although the current group of infants and young children will not reach full facial growth for more than another decade and a half, and therefore await critical assessment of their long-term outcomes, the authors hope that the experience gained to date will assist surgeons in managing these complex reconstructions.

Scar-Saving Flap during Serial Excision by Borrowing from the Opposite Side

BACKGROUND

Congenital melanocytic nevi may have various shapes according to the anatomic location. Therefore, it is desirable to apply proper surgical designs to the diverse forms considering the characteristics of the sites as well as the shape and size.

OBJECTIVE

The purpose of this article is to introduce a new scar-saving flap design for semicircular defects after removing congenital melanocytic nevi without excising additional normal skin.

METHODS

In most cases to excise semicircular nevi, normal skin should be excised to prevent dog ear, resulting in the long length of the scar. So we use a new scar-saving flap design by borrowing a partial length from the opposite side.

RESULTS

We used this new technique for 4 cases of large semicircular skin defects. In all cases, this method had some advantages from this perspective: (1) it does not require excision of normal adjacent skin to convert a semicircular defect into a crescent shape or to remove dog-ears (2) the final suture line is not much longer than the diameter of the original defect and (3) it makes the removal of a much larger volume possible in one procedure rather than using the classic serial excision technique, which consists of a central elliptical excision within the confines of the nevus. In this way the frequency of procedures and discomfort to the patient can be reduced.

CONCLUSION

We think that a scar-saving flap design by borrowing a partial length from the opposite side can be a good strategy for a semicircular skin defect.

Giant congenital melanocytic nevi

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Define what is meant by a giant congenital melanocytic nevus and understand its histologic properties. 2. Know the natural history and potential complications associated with a giant congenital melanocytic nevus. 3. Outline the nonsurgical and surgical options available to treat a giant congenital melanocytic nevus.

BACKGROUND

Giant congenital melanocytic nevi are rare lesions with a propensity to degenerate to malignant melanoma. Certain lesions also may be associated with neurocutaneous melanosis, which can on occasion be symptomatic. Appropriate investigations include a screening magnetic resonance imaging scan, neurologic evaluation, and serial clinical observations for the development of cutaneous melanoma. A variety of nonsurgical and surgical options are possible for the treatment of giant congenital melanocytic nevi.

METHODS

A MEDLINE search was performed to gather all pertinent articles from 1955 to 2005.

RESULTS

Giant congenital melanocytic nevi are a difficult diagnostic and reconstructive challenge, requiring careful preoperative evaluation, staged surgical excision, and lifelong patient monitoring and follow-up. With proper treatment, patients can expect a decreased risk of melanoma, with the possibility for early detection and cure of melanoma, amelioration of symptoms, improved aesthetics and psychosocial sequelae, and maintenance of function.

CONCLUSION

The plastic surgeon treating these challenging lesions must have a solid working knowledge of the disease's histology, its natural history and complications, and the options for treatment.

Repeated tissue expansions on split-thickness skin graft in a patient with neurocutaneous syndrome

Soft tissue expansion is a mechanical process that increases the surface area of local tissue available for reconstructive procedures. In most cases, adjacent tissue that matches the recipient site in color, texture, and hair-bearing quality is preferred for tissue expansion. In this particular case with neurocutaneous syndrome, the defects that resulted from removal of parts of a giant hairy nevus overlying the latissimus dorsi muscle bilaterally were grafted with a split-thickness skin graft. Two expanders were then placed under the latissimus dorsi muscles. After full expansion of the grafted area, some part of the remaining nevus surrounding the grafted area was removed and the defects were covered with the expanded skin graft obtained after deflation of the expanders. The expanders placed under the latissimus dorsi muscle in the first operation were reused in the second operation to obtain a second expansion of the skin graft. After the second expansion of the skin graft, the expanders were deflated and another portion of the remaining nevus surrounding the grafted area was removed. The resulting defects were again covered with the excess expanded skin graft. Although repeated expansion of the skin graft is a time-consuming and laborious process, it eliminates the need for taking repeated skin grafts; it decreases skin graft donor site morbidity; it decreases possible infectious complications of tissue expansion by decreasing the number of surgical interventions to the expander pocket; and it increases the aesthetic outcome by keeping all the surgical scars around the grafted area without extending them into healthy surrounding skin.

Nevus Sebaceus of Jadassohn

The nevus sebaceus of Jadassohn (SNJ) is a hamartomatous disorder of the skin and its adnexa pertaining to the group of "organoid nevi,'' most frequently involving the face and scalp. During adulthood, patients with SNJ have a 10% to 20% risk of the development of cutaneous or adnexal neoplasia, so that prophylactic excision before puberty is recommended by most authors, and tissue expansion is considered to be the best method of reconstruction. It has been largely demonstrated in literature that most of the lesions that have been interpreted as basal cell carcinoma (BCC) are actually examples of primitive follicular induction or trichoblastomas, not authentic BCCs. A literature review on histopathologic findings associated with SNJ and a retrospective chart review of two cases occurring in young females are presented. In one case, the lesion was treated by intraoperative expander-assisted reduction and scalp graft (Case 1); in the other one, a primary closure with adjacent tissue was performed (Case 2). No signs of malignant degeneration or residual pathology have been found. For treatment of the biggest lesions, when preoperative tissue expansion cannot be performed, intraoperative one, transfer of a scalp graft has been shown to be a good reconstructive method. For the smallest lesions, a primary closure with adjacent tissue is sufficient.

Skin Regeneration for Giant Pigmented Nevus Using Autologous Cultured Dermal Substitutes and Epidermis Separated From Nevus Skin

We have developed a modality of treatment of giant pigmented nevus of intradermal type. This method involves application of autologous cultured dermal substitute (CDS), followed by grafting of epidermis separated from the patient's nevus skin. To prepare the wound bed, autologous CDS was applied onto a full-thickness skin defect after complete excision of the nevus. The excised nevus skin was preserved for 1 week, after which the epidermis was separated from the nevus skin by enzymatic treatment with dispase. The epidermis thus obtained was grafted onto the resulting wound bed. This procedure was used to treat a giant pigmented nevus on a 7-year-old patient. The grafted region was soft with good tone 1 year after epidermis grafting. These results indicate that the present method can achieve complete excision of giant nevus, with esthetically acceptable results, although it requires careful monitoring for a long time.

Giant congenital melanocytic nevi of the trunk and an algorithm for treatment

Giant congenital melanocytic nevi (CMN) are rare, congenital, disfiguring lesions with a risk of degeneration to malignant melanoma. Giant CMN are associated with an increased risk of malignant degeneration. In a minority of cases, patients with giant CMN may have associated neurocutaneous melanosis with leptomeningeal involvement. Giant CMN of the trunk pose difficult diagnostic and reconstructive problems requiring complex multistage treatment. For high-risk cases, diagnostic evaluation in the form of neuro-imaging is an essential component of the planning phase. Although nonsurgical options for the treatment of giant CMN have been advocated, these modalities may decrease the burden of nevus cells but do not result in complete removal of these cells. The ability to monitor nevus cells that remain after nonsurgical management of giant CMN remains questionable. These nonsurgical options include dermabrasion, laser ablation, and chemical peel. In contrast, direct excision of the nevus is the mainstay of treatment of nonsurgical management of giant CMN. There are numerous surgical options to resurface the resultant cutaneous defect after excision of the nevus. The simplest of these options consists of serial excision and direct closure of the defect in stages. However, if the defect cannot be closed by direct cutaneous advancement, other options for wound resurfacing include split- or full-thickness skin graft, tissue expansion, and free tissue transfer. Tissue expansion should be viewed as a category of treatment options because expanders can be used to create an expanded full-thickness skin graft, local expanded flaps adjacent to the lesion, or expansion of a free tissue donor site. Given the diversity of reconstructive options that use tissue expansion, these techniques have evolved as the primary treatment method for giant CMN of the trunk. The authors outline an approach to the evaluation of giant CMN of the trunk, review the risks of melanoma and of neurocutaneous melanosis, describe their preferred treatment regimen, and offer a treatment algorithm for giant CMN of the trunk.

Congenital melanocytic nevi needing treatment

Patients presenting with congenital melanocytic nevi (CMN) need individualized treatment based upon nevus size, thickness, location, risk for developing melanoma, and psychological characteristics of the patient and family. The present authors review CMN types and prognoses, as well as absolute and relative indications for treatment. Risks and benefits of several treatment options are discussed, including surgical options, such as excision, chemical peels, dermabrasion and curettage, and laser therapy. The main focus of treatment is, in all cases, to address the concern for developing melanoma, at the same time optimizing the aesthetic and functional outcomes.

Tissue expansion in pediatric patients

Tissue expansion has become a well-recognized technique for reconstructing a wide variety of skin and soft tissue defects. Its application in the pediatric population has allowed the plastic surgeon to achieve functional and aesthetic goals that were previously unobtainable. This technique can be applied to a variety of reconstructive problems, including the management of giant congenital nevi and the secondary reconstruction of extensive burn scars. This article reviews the use of tissue expansion in the pediatric population, with particular emphasis on indications, operative technique, and regional considerations. The authors also address concerns that have been expressed about the complications associated with this technique.

Treatment of large and giant nevi

Excision of large and giant melanocytic nevi presents a distinct challenge to the pediatric plastic surgeon. The exact risk of malignant degeneration remains unknown. These unsightly lesions can be psychologically damaging to both parent and child. The pediatric plastic surgeon must have an armamentarium of techniques for reconstructing the various body areas and must always balance aesthetic and functional outcomes against an unknown but low risk of malignancy.

The Expanded Transposition Flap: Shifting Paradigms Based on Experience Gained from Two Decades of Pediatric Tissue Expansion

The authors present their experience with the design of expanded skin flaps gained over the past two decades in a large series of 995 expanded flap reconstructions performed in 626 operations in 430 patients. The indications for tissue expansion were giant congenital pigmented nevi (72.7 percent), scar contractures (11.2 percent), and a remainder for a variety of congenital and acquired deformities. Surgical strategies were reviewed retrospectively to determine the location in the body where the tissue expansion was performed, the number of procedures required to accomplish the reconstructive goal, and the design of the expanded flap that was used to reconstruct the involved area. Specific points that were noticed included contour deformities (such as webbing, dog-ears, or decreased limb circumference) following flap reconstruction, anatomic distortions (such as distortion of the eyebrow or the distance from the brow to hairline) following reconstruction, final position of the scars in relation to anatomic landmarks, borders of aesthetic units, and relaxed skin tension lines, and the potential for later scar contracture. Careful examination of reconstruction by region of involvement demonstrated significant advantages in the use of expanded transposition flaps over pure advancement. These advantages and the modifications in the design of expanded flaps for each body region are discussed in a series of representative cases. They emphasize the ability of transposition flaps to dissipate tension away from the flap apex and distribute it more proximally, thus redirecting the tension lines so there is less likelihood of anatomic distortion in the reconstructed area. Also, flaps designed in this manner allow improved contour by avoiding webbing, tenting across concavities, and bunching of skin laterally. The authors conclude that restricting the expanded flap design to advancement alone to minimize potential scarring severely limits the reconstructive capabilities of the added tissue and distracts from the surgeon's ability to accomplish the initial reconstructive goal. The cost of additional incisions is worthwhile to achieve better final contour of the reconstructed part, lesser risk of anatomic distortion, better position of the scars, and lowered risk of scar contracture.

Pediatric tissue expansion: indications and complications

Tissue expansion has become a major reconstructive modality in the past 30 years. Its application in the pediatric population has allowed the plastic surgeon to achieve functional and esthetic goals that were previously unobtainable. Tissue expansion is a major treatment modality in the management of giant congenital nevi and secondary reconstruction of extensive burn scars, allowing sensate tissue of similar color, texture, and thickness to be used to resurface the affected areas. One must be prepared for complications when using tissue expanders, however, because complications are inherent in the process of expanding skin utilizing repeated filling of implanted foreign bodies. Complication rates increase when serial expansion of the same tissues is performed repeatedly or if expanders are placed in the lower extremities. Outcomes are dependent on thorough planning, meticulous technique, close follow-up, and patient compliance. Tissue expansion has revolutionized plastic surgery in the last 30 years. This technique can be applied to a considerable breadth of reconstructive problems in the pediatric population. Tissue expansion has permitted the plastic surgeon to achieve the goals of reconstruction with tissue of similar color, texture, and thickness, with minimal donor site morbidity. Preservation of sensation in a durable flap has allowed the surgeon to achieve acceptable functional as well as esthetic goals simultaneously.

Large and Giant Congenital Pigmented Nevi of the Upper Extremity: An Algorithm to Surgical Management

The timing and choice of treatment of congenital giant pigmented nevi continues to evolve under the influence of changing opinions regarding the risk of malignant degeneration and the impact of excision and reconstruction on the affected child. Many studies exist to support a notable enough risk of malignancy to warrant excision, yet other series and pigmented lesion clinics suggest that the risk of malignancy does not warrant the potential scarring and deformity that has followed the surgery necessary to remove these giant lesions. To satisfy both sides in this controversy, we have been challenged to modify our surgical techniques in a manner that minimizes the risk of malignant degeneration and at the same time provides optimal functional and aesthetic outcomes for these complex reconstructions. Thirty consecutive patients with large and giant nevi of the upper extremity were treated over a 23-year period (1979-2002) by the senior author. These patients represent a subset of 259 children (12%) with large or giant congenital pigmented nevi treated and followed during this period of time. In proximal upper extremity lesions, expanded transposition flaps from the upper back and shoulder have effectively eliminated contour defects or circumferential constriction in the upper arm and axilla. An expanded free transverse rectus abdominis musculocutaneous flap has offered a possible avenue for larger lesions (shoulder and upper extremity to below the elbow), and pedicle flaps from the flank (both expanded and nonexpanded) have offered ways of improving the long-term contour in the forearm. Expanded and nonexpanded full-thickness skin grafts were chosen for reconstruction of the hand and the fingers. The authors describe in detail the surgical strategies and the techniques for reconstruction of each region of the upper extremity and then bring these ideas together in an algorithm for assessment and treatment of these challenging lesions.

Radical resection of giant congenital melanocytic nevus and reconstruction with meek-graft covered integra dermal template

BACKGROUND

Giant congenital melanocytic nevi represent a surgical challenge, particularly in cases in which the size of the nevus exceeds certain extend and malignant transformations have to be considered.

OBJECTIVE

To discuss through case report considerable surgical options when extensive giant congenital melanocytic nevi with malignant transformation are encountered.

METHODS

We present an unusual case of a giant congenital melanocytic nevi of the entire back of a 44-year-old patient. To achieve radical resection with direct appropriate wound closure and acceptable outcome, the integument of the entire back was excised and covered with Integra, followed by split-thickness skin grafting after stable integration of the matrix.

RESULTS

The approach resulted in a complete excision of the tumor and acceptable cosmetic and excellent biomechanical outcome.

CONCLUSION

The introduced practice demonstrates a useful alternative to established methods, particularly if tumor excision in large areas and subsequent wound closure might be achieved in one procedure.

Surgical management of the cutaneous manifestations of linear nevus sebaceus syndrome

Linear nevus sebaceus syndrome is characterized by the association of nevus sebaceus covering extensive areas on the head and scalp with abnormalities of the central nervous system, ophthalmologic and skeletal changes, and malignancies. The incidence is approximately one per 10,000 live births, and there is no sexual predilection reported. The original description of this syndrome was followed by extensive literature describing the dermatologic, neurologic, and ophthalmologic manifestations of this disease. The objective of this report is to describe the surgical approach for the excision and reconstruction of giant sebaceous nevi of the face and scalp in children with linear nevus sebaceus syndrome on the basis of a consecutive series of five patients treated over 10 years in the same institution. To the authors' knowledge, this report represents the largest surgical series and suggests a reliable approach to the treatment of the cutaneous manifestations of this syndrome.

[Burned lips]

The burns of the mouth and the lips, even electric are rare. The respect of the news prevention's norm modify the incidence of these burns. The progress of the management these last 40 years, contributed to the improvement of the functional and aesthetic prognosis. The early surgical intervention has been modified for a conservative approach. Three points are discussed by authors: anatomoclinical particularities in case of different burning; early management; sequelae treatment.

Reconstructive surgery using an artificial dermis (Integra): results with 39 grafts

Integra was initially developed for the primary coverage of acute burns. It acts as a network for dermal reconstruction. An epidermal graft overlay is necessary after 3 weeks to achieve the in vivo reconstruction of a full-thickness skin equivalent. The quality of the functional and aesthetic results achieved led us to evaluate the potential of Integra in the treatment of burn scars and for general reconstructive surgery. We present a series of 31 patients who underwent Integra grafting for reconstructive surgery at a total of 39 operational sites. The average area grafted per procedure was 267 cm(2). Complications (silicone detachment, failure of the graft, haematoma) were observed in nine cases. The length of follow-up ranged from 0.5 year to 4 years. Two patients (two sites) were lost to follow-up; the final results in the remaining patients were considered to be good in 28 cases, average in six cases and poor in three cases. The disadvantages of using Integra in reconstructive surgery are the necessity of two operations, the risks of infection under the silicone layer, of the silicone becoming detached and of recurrence of contraction. On the other hand, Integra has many advantages including its immediate availability, the availability of large quantities, the simplicity and reliability of the technique, and the pliability and the cosmetic appearance of the resulting cover. In the light of these preliminary results, Integra appears as a new alternative to full-thickness skin grafting, skin expansion and even skin flaps for reconstructive surgery.

Skin grafting of the naso-orbital region as a single aesthetic unit

With improved acute care, a higher percentage of more severely injured facial burn patients are surviving their burns. When the full face needs resurfacing, total facial resurfacing should ideally be done with a single sheet of full-thickness skin. Unfortunately, this type of single sheet total facial resurfacing is rarely possible or practical in the case of acute extensive burns. The nasoorbital region is a focal point of interpersonal communication and needs special emphasis. This report presents two patients with deep facial burns whose midface regions were resurfaced with thick split-thickness skin graft as a single aesthetic unit. Since there is no skin graft junction line on this region, a more homogeneous appearance and an aesthetically superior result could be achieved.

Grafting of large pieces of human reconstructed skin in a porcine model

Present techniques can save about 25% of patients burnt over more than 90% of their body surface. However, problems of functional and aesthetic repair arise, which are often resolved only by major therapeutic procedures. Current advances in skin substitutes permit the cultivation, from a skin biopsy, of large surfaces of in vitro human reconstructed skin (HRS). Our model, obtained by the co-culture of fibroblasts and keratinocytes on a dermal substrate composed of collagen-glycosaminoglycan-chitosan, reproduces, in vitro, a tissue close to human skin, which could play a role in reconstructive surgery. The objectives of this experiment were to assess whether it is possible to perform large HRS grafts and to evaluate the preliminary cosmetic results. We used four immunosuppressed female pigs. Full-thickness skin resections of 50-100 cm(2)were performed on the dorsa of the animals. The defects were grafted with between one and six pieces of HRS under tied-over dressings. At day 14, we found a soft and smooth surface of good transparent healthy pink skin, which was very easy to distinguish from the surrounding tissues. The junctions between different pieces of living skin were not visible. Immunohistological studies with specific anti-human keratin 14 antibodies confirmed the graft take: 7 days after grafting the human epidermis was attached to the living dermis and showed good organisation with a basal cell layer and suprabasal cells; 28 days after grafting the human epidermis seemed to be replaced by pig epidermis. This study highlights the possibility of grafting large surfaces with HRS using a routine operating technique.

[Reconstruction of facial burn sequelae]

The deep burns of the face can lead to horrible scars functionally and aesthetically. Treatment of these scars need several surgical interventions frequently and during many years. In our region we deal with this type of wounds as team work, multidisciplinary approach carrying out many process starting by emergency treatment of acute burns till the social rehabilitation. The expansion technique was great help in improving the shape of scars, by using the expanding skin as full thickness grafts. Reconstruction of the anatomical units and application of aesthetic techniques (like rhinoplasty, lifting, tattooing and autologous fat injections) participate equally in improving the quality of results. Many examples of treatments of burns scars are shown.

The cosmetic split-thickness skin graft donor site

Any split-thickness skin graft donor site is obvious to some degree because of pigment alterations and, at the worst, it can develop hypertrophic scarring. A predictably superior aesthetic result is possible if this site is converted to a full-thickness defect followed by primary closure, because a linear scar is the only residuum. Using a modified tumescent technique, the groin can also be readily used as a split-thickness donor site if a thin graft is preferred; it captures the attributes of an ideal donor site in which pain is diminished, healing rapid, and the scar inconspicuous, just as when it is used as a full-thickness skin graft donor site.

Neurocutaneous syndromes associated with pigmentary skin lesions

Tremendous strides have been made in our understanding of genetic disorders, including those that involve both the skin and the nervous system. The list of well-established neurocutaneous syndromes has increased during a few decades from a few classical phakomatoses to more than 30 entities. The dermatologist has the opportunity to facilitate precise diagnosis and optimal care for these patients by recognition of the cutaneous markers for these diseases. We have attempted to provide an overview of some recent advances in those syndromes manifested by pigmentary skin changes, emphasizing the clinical spectrum of each disorder and providing guidelines for an approach to management.

The use of tissue expansion in children with burns of the head and neck

The outcome of 25 children who underwent reconstruction of the head and neck with tissue expanders is described. Fourteen boys and 11 girls with a mean age of 6.2 years (range 3-11 years) had 36 tissue expanders inserted. Five of the expanders extruded and five children suffered other expander-related complications. The best aesthetic results were achieved in the scalp and the poorest results occurred where expanded neck skin was transposed into the face. Tissue expansion is a useful method for reconstruction of the head and neck in burned children. However patients require careful selection in order to achieve optimal results. Meticulous attention to detail is required to reduce the incidence of complications.